Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies.

Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures.

The law requires that I obtain your signature acknowledging that I have provided you with this information. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

THE COUNSELING PROCESS  

The Counseling Process Counseling is one way in which to identify and address personal, emotional or relational issues and a person can usually expect relief of symptoms through the counseling process. Studies and our experience have shown that the therapy process often works to bring solution and relief in a wide variety of situations.

Improvement is not always the case, however, and even for people whose situations and symptoms do improve over time, there may be periods of increased difficulty as personal histories, relational patterns or habits of thinking and behaviors are explored and addressed. If there comes a time when the focus of treatment requires attention from a professional in another area of specialty, we will work to provide appropriate referrals.

CONTACTING ME 

Due to my work schedule, I am often not immediately available by telephone. I do not answer the phone when I am with a client. When you
contact Grow Therapy, you are greeted by a menu of options that includes the option to speak with a support staff. This support staff is off-site,
knows me by name, and can take calls regarding scheduling, or other issues.

If you feel the need to leave me a direct message, you may do so by emailing me through a secure and HIPPA compliant email address.  Once I receive an email from you, I will make every effort to respond within 24-48 hours of receiving it, with the exception of weekends and holidays.  If you are difficult to reach please inform me of some times when you will be available.

If you are unable to reach me and feel that you can’t wait for a return email, contact your psychiatrist, family physician, or nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. Please also see below for my Social Media / Email policies.

APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session should be discussed with the therapist in order for time to be scheduled in advance.

No Shows, Cancellations, and Re-scheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

INSURANCE  
The administrative staff at Grow Therapy can help you with questions about insurance and can bill your insurance company for you, however each client is responsible to understand their own benefits and maintain communication with their insurance company as needed. Insurance coverage varies significantly between companies. In order to submit claims we will need to submit the date of service, service code and diagnosis code.

Most insurance provides for mental/behavioral health coverage, however, some insurers require pre-‐authorization, which may require an initial call from you or may limit your choice of service providers. Please call your insurance company to clarify coverage and consult with Grow Therapy for more
information.

CONFIDENTIALITY  

Psychotherapy is confidential, including all communication between client and therapist, is a confidential service protected by law. In most situations your therapist can only release information about your treatment to others whom you specify in a
signed written authorization. However, in certain situations no authorization is required.

Your therapist may find it helpful to consult with other clinical professionals about your treatment. In these instances every effort is taken to avoid revealing your protected healthcare information. Other professionals are
legally bound to maintain the confidentiality of a consultation. Unless you object, your therapist will not tell you about these consultations, as they are a normal part of delivery of services.

SPECIAL CONFIDENTIALITY: Minors and Parents  

We strongly believe that for therapy to be helpful to an adolescent, there needs to be as much confidentiality for them as possible in the therapy process. That is, unless the issue falls into the following categories…

--your child is clearly unsafe or at risk of harming themselves

--your child is at risk of being harmed by anyone else

--your child is at risk of harming someone else

--we are required by a court to disclose treatment records

In which case we would follow the clinically and legally appropriate reporting requirements. Outside of this, we will encourage your child to express themselves freely, and assure them that there will be confidentiality provided to them in this process. We need your child to be open and honest with us in order to understand and treat the full range of issues your child is facing, and they may be too scared, angry, or ashamed right now to share those issues with you. We also recognize it is very important for you to know what your child is going through in order to do your job as a parent, which is why we will always encourage your child to be honest with you. We will encourage, prepare and support your child so that they feel safe enough to share those issues with you, and we are happy to facilitate family meetings whenever helpful and appropriate.

LIMITS OF CONFIDENTIALITY  

In some situations, we are legally obligated to take action that will likely reveal information about your sessions to an outside party, possibly without your consent. These situations are rare and are limited to circumstances in
which harm to you or another person is likely, such as:

Duty to Warn: Therapists are mandated by law to disclose pertinent information
discussed in therapy if the client has an intent or plan to harm another person. We are required to inform the intended victim and notify legal authorities.

Suicide/Self harm: Depression is common emotion expressed in therapy, but if a client is feeling hopeless enough to imply or disclose a plan for suicide; steps need to be taken to ensure safety.

This would include notifying the legal authorities as well as make reasonable
attempts to notify the family.

Animal abuse: I will report animal abuse, including cases of neglect and hoarding.

Vulnerable Adults and Children: Mental health professionals are required by law to report stated or suspected abuse of a child or vulnerable adult to the appropriate social service agencies and/or legal authorities.

Prenatal Exposure to Controlled Substances: in keeping with protecting vulnerable populations, Mental Health Providers are required to report admitted use of controlled substances during pregnancy that are potentially harmful to the fetus.

Minors/Guardianship: Parents or legal guardians have the right to access a minor client’s health information. Age of adult for psychotherapy is .

Insurance Providers: Information requested includes description of impairments, dates and times of service, diagnosis, treatment plans, treatment progress, prognosis for improvement, case notes and summaries.

I have read and understand the above-stated limitations to confidentiality. I accept the subsequent ramifications should there be a need to act on one of the abovestated exceptions. Other than the noted exceptions, if there are reasons to disclose my protected confidential information I understand that I will be provided a Release of Information form.

SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

TERMINATION  
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

CREDIT CARD AUTHORIZATION
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as PEACEFULLY YOU, LLC. You have the right to request a paper copy of this document.

I authorize PEACEFULLY YOU, LLC to charge my credit card through Stripe. [CANCELLATION POLICY: I also agree that my credit card can be charged for any session that is not canceled at least 24 hours prior to the scheduled session].

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify PEACEFULLY YOU, LLC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS.