Welcome to Mend! In order to provide the most effective therapy, there are important details to share. Please read the following and discuss any questions with your therapist before you sign. Your therapist, as a partner at Mend Couples Therapy LLP, is solely liable for your treatment.

Education & services: We provide tele-health therapy for individuals, couples, and families using a combination of Emotionally Focused Therapy (EFT) and EMDR. All partners are Licensed Clinical Social Workers, certified in EFT at the therapist and supervisory level, and EMDR trained.

Tele-health benefits & risks : Telehealth therapy is effective and convenient. Benefits can include increased resiliency and emotional regulation, distress reduction, improved relationships, and an overall improvement in well-being. It can stir up painful emotions and or memories, and while benefits are the desired and expected outcome, no specific outcome can be guaranteed.

Even with end-to-end encrypted software and full HIPAA protection, the possibility of data interception from unauthorized persons still exists in tele-health therapy. When you agree to therapy via technology, you agree to waive your protection of confidentiality with respect to information exchanged during the session that may be accessed by an unauthorized third party.

Further risks and limitations of tele-health include: potential for dropped, distorted, or unclear signals, and the loss of clinical information more easily obtained in a face-to-face session. All of these can disrupt the flow of the session, cause potential misunderstandings, or even impact your therapist's diagnostic or clinical recommendation.

Please treat tele-health appointments like an in-office visit. Give yourself time to transition into and out of your session. You will need a quiet, private space with a strong and reliable wi-fi signal. Your screen needs to be large and stationary. Do not plan on using your iphone or similar sized hand-held device. If a session becomes glitchy, you will need to troubleshoot, which might include disconnecting and reconnecting to the session. If troubleshooting doesn't resolve the technology problem, your therapist will contact you to reschedule.

As telehealth providers in Virginia, our clients must be state residents. To verify residency, your therapist will need a copy of your driver's license.

Getting started: Sessions # 1-4 are for assessment purposes. We want to ensure that our training, treatment recommendations, personal style, and virtual office work for you. Should we recommend a different type of therapy, additional mental health services, a face-to-face provider, or other treatment modality, referrals will be provided.

Confidentiality: All communications will be kept confidential. Unless mandated by law, your provider will seek your consent prior to releasing any confidential protected health information (PHI Further details can be found in our HIPAA policy.

Confidentiality specific to relationship therapy: In relationship therapy, there is one shared medical record. In order to release information from this record, your therapist will seek permission from all adult parties. Because the therapeutic focus is your relationship and the preservation of it, we request that you commit to keeping all information revealed during therapy, whether verbal or written, out of judicial settings. This commitment ensures that all parties can be open and honest.

Your provider is not obligated to hold confidences between partners or family members. Sharing information privately with your therapist that you are unwilling to share with your loved ones might be a contra-indication for ongoing relationship therapy.

Email and social media: As a practice, we avoid doing therapy via email, but we use it regularly for administrative purposes. Our standard practice is to use regular email for basic administrative issues, like appointment scheduling, and secure email for any communications containing detailed health information, such as insurance super bills. We cannot guarantee these communications will remain confidential. 

The relationship between client and therapist is a professional service relationship. Therefore, your therapist cannot connect with you on any social media, nor enter into any other business or social relationship with you.

Scheduling: Appointments are typically scheduled on a weekly, repeating basis. If you can no longer attend your weekly time slot, your therapist will attempt to accommodate the schedule change. Unfortunately, she cannot guarantee alternate availability.

Cancellation policy: 24 hours notice, via email or phone, is required for all cancellations. The late cancellation fee is $50 and the no-show fee is $100. Because life happens, all clients are given one free late cancellation.

Session Fee: The initial intake appointment fee is $275. The regular session rate is $215 per 52-minute session. At the end of assessment, you will receive a Good Faith estimate of potential treatment costs from your therapist.

Payment: We accept electronic payment via Square. Your therapist will invoice you for each session, and payment is due upon receipt. We offer automatic billing to clients who wish to store their card with

Account balances: Any account balance that remains unpaid, despite a direct payment request, will result in the suspension of all non-emergency services until the balance is paid in full.

Insurance: All providers at Mend Couples Therapy, LLP are out-of-network providers and thus cannot guarantee any payment from your insurance. If appropriate, and upon request, your therapist can provide you with a specialized insurance receipt so you can seek reimbursement. Should you wish to file out-of-network claims, you will need to provide your therapist with proof of identity. Please note, your therapist will not communicate with your insurance carrier.

Records: Records are stored according to HIPAA standards, and include your attendance, payment record, notes from each session, and other health information. Medical records are stored for 7 years. Our privacy policy outlines the handling and confidentiality in more detail.

Treatment termination and referrals: Any issues that might lead your therapist to terminate treatment will be addressed with you directly. These could include, but are not limited to: a lack of progress, poor compliance, attendance or scheduling issues, ongoing technology challenges, lack of payment, safety issues, or emergence of any new or previously unknown contraindications. Should termination occur, you will be provided with appropriate referrals. We encourage you to discuss therapy concerns with your therapist prior to terminating treatment.

Emergency Procedures: Your therapist is not an emergency or crisis provider. If you are having a mental health crisis or emergency, please call 911 or go to your nearest emergency room. After you have been seen by the emergency room staff, please call 703-687-6967 to contact your therapist.

Consent: By signing below, you are giving permission for your therapist at Mend Couples Therapy, LLP to provide you with mental health services. Your signature indicates that you have read and understand this document of informed consent, agree to abide by the terms, and have no further questions about any of the information contained within. All participating parties must sign. Parents or legal guardians must sign for minors.

Your health record contains personal medical information about you, often referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI and your rights to access and control it. We are required to provide you with this notice and to abide by its terms. We reserve the right to change the terms.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

1. For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment. This includes consultation with clinical supervisors or other treatment team members.

2. For Payment. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount.

3.Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of HHS for the purpose of investigating or determining our compliance with HIPAA.

Disclosures Without Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which you can revoke at any time. However, the following disclosures are permitted by HIPAA without your written consent. The exceptions include:

1. Child Abuse or Neglect. We must disclose your PHI to a state or local agency authorized by law to receive reports of child abuse or neglect.
2. Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
3. Deceased Patients. Based on prior consent, we may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment.
4. Medical Emergencies. We may disclose your PHI in a medical emergency situation to medical personnel, only in order to prevent serious harm. Should your therapist ever become incapacitated, she will designate a therapist of her choosing to store and handle your record.
5. Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
6. Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
7. Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document.
8. Specialized Government Functions. Disclosures to U.S. Military Command and National and Security Intelligence Organization will be based on your written consent, mandatory disclosure laws, and the need to prevent serious harm.
9. Public Health. If required by a public health authority, we must disclose your PHI for mandatory public health activities.
10. Public Safety. We must disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
11. Verbal Permission. We may disclose your information to family members that are directly involved in your treatment with your verbal permission.

YOUR RIGHTS REGARDING YOUR PHI: You have the following rights regarding your PHI. To exercise any of these rights, please submit your request in writing to your therapist.

1. Right of Access to Inspect and Copy. You have the right to inspect and copy PHI maintained in your medical record. This right will be restricted only if there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes.
2. Right to Amend. You may ask us to amend any PHI that you feel is inaccurate, but we are not required to agree to it. If we deny your request, you have the right to file a statement of disagreement with me.
3. Right to an Accounting of Disclosures. You have the right to request an accounting of PHI disclosures.
4. Right to Request Restrictions. You have the right to request a restriction on the disclosure of your PHI. Since you pay out of pocket, we are required to honor your request.
5. Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We will not ask you for an explanation for the request.
6. Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
7. Right to a Copy of this Notice. You have the right to a copy of this notice.
8. Right to file a complaint. If you believe we have violated your privacy rights, you have the right to file a complaint in writing to your therapist or the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202)619-0257.

Because each therapist at Mend is an independent clinical provider, your therapist is the point of contact regarding HIPAA compliance and security. All questions or issues regarding PHI and HIPAA should be directed to your provider.

By signing below, I acknowledge that I have been provided a copy of my provider's current Privacy Policy. I understand that should this policy change, I will be notified.