6 Week Skills Course

Please complete the assessment completely. We require the individual to complete for themselves and cannot be completed on their behalf. If the questions asked below bother you, please schedule with us for a phone assessment. If experiencing a crisis currently, call #988. During the past TWO WEEKS, how much or how often have you been bothered by the following problems?

Please complete the assessment completely. We require the individual to complete for themselves and cannot be completed on their behalf. If the questions asked below bother you, please schedule with us for a phone assessment. If experiencing a crisis currently, call #988. During the past MONTH:

6 WEEK SKILLS COURSE The Skills Course is a mutually agreed upon therapeutic process of social engagement occurring between a professional psychotherapist and group clients. In the skills support process, the therapist will help the individual, and the group, define his/her/their goals, explore a path of client self discovery, increase understanding of how to cope with the world around them, and attain improved functioning and symptom relief whenever clinically possible. TELEHEALTH Variously dubbed telemedicine, teletherapy, distance therapy, e-therapy, internet therapy, or online therapy, “telehealth” is defined as the use of electronic transmission to provide interactive real-time mental health services remotely, including consultation, assessment, diagnosis, treatment planning, counseling, psychotherapy, coaching, guidance, psycho-education, and transfer of medical information with an experienced therapist. This can include both video and audio forms of communication, via the internet or telephone. *Telehealth services do not include texting or e-mail. RELATIONSHIP Safety is the highest priority for clients. In order to keep clients safe, and provide the most effective therapeutic environment possible, the relationship between therapist and clients must be kept strictly professional. The therapist cannot engage with the client in any other type of(dual) relationship. The therapist is unable to acknowledge the client in any public setting. However, the client may acknowledge the therapist in any public setting. CONFIDENTIALITY Still Move Counseling highly respects the privacy and confidentiality of each client. For the skills course to be effective and successful, client information is kept confidential. In other words, what a client discloses in a group session will not be shared with anyone. Group members are instructed to keep each other's information confidential. Still Move Counseling reserves the right to share confidential information with the covering on-call Still Move Counseling clinician for emergency situations and for continuity of care (see privacy limitations for legal exceptions). The same laws protecting the confidentiality of your health information in the office apply to telehealth sessions, including mandatory reporting and permitted exceptions, such as child, elder and dependent adult abuse reporting, risks to the client’s wellbeing, threats of violence to an identifiable victim and when clients enter their own emotional or mental factors into a legal proceeding. The client and therapist both agree to keep the same privacy safeguards used during group sessions. Ensure that your environment is free from unexpected or unauthorized intrusions or disruptions to our communication.*You are asked to preserve privacy and limit the risk of being overheard by a third party by conducting the session in a private room with closed doors, with reasonable sound barriers, and no one else present or observing. Earphones may be very helpful to help you preserve privacy as well.*The client and therapist both agree to not record the telehealth sessions without prior written consent. SECURITY No electronic transmission system is considered completely safe from intrusion. While a variety of software programs are available for video conferencing, such as Zoom, Skype, Facetime, or GoToMeeting, most are not encrypted, or compliant with Federal law to protect the privacy of your health communication. *We will be using Zoom for group class. It is Still Move Counseling, LLC’s understanding that Zoom is HIPPA compliant. Interception of communication by third parties remains technically possible. *You are responsible for information security on your own computer, laptop, tablet, or smartphone. Due to the complexities of electronic media and the internet, the risks of telehealth include the potential for the release of private information, including audio, written materials and images which may be disrupted, distorted, interrupted or intercepted by unauthorized persons, despite your therapist’s reasonable efforts. *Consequently, your psychotherapist cannot guarantee the security of telehealth sessions. ZOOM Zoom will be the video platform used for group therapy session. Zoom is only partially HIPPA Compliant. Still Move Counseling, LLC is not responsible for class breaches, interruptions, or technical disruptions due to the zoom software. Still Move Counseling, LLC is not liable if any information is hacked or recorded without knowledge or consent while participating in group. RECORD MANAGEMENT Clients' records are stored in a HIPAA compliant secure manner. Clients’ records are not accessed or shared with anyone else unless the client provides written consent to release specifically identified information to the receiving party. All clinical records that have not received any update within a period of 7 years are purged in a HIPPA compliant manner. CONFIDENTIALITY/PRIVACY LIMITATIONS. Privacy has its limitations. By law, these are the circumstances where client information may be shared to a 3rd party without their consent: Acts of sexual abuse or misconduct. Criminal acts. Acts of abuse towards others such as neglect towards children, disabled, or the elderly. Acts that the therapist believes may cause harm to the client himself/herself or to others. Verbal reports of self harm or harm to others with identified plan and/or intent. Compelling legal orders by the court. The client will be informed immediately prior to compliance with the order. Minors. In cases where the client is not yet 18 years old, necessary information will be disclosed to parents or legal guardians. INSURANCE (THIRD PARTY) PAYMENT PROCESSING Still Move Counseling, LLC, does not submit claims to insurance companies for group therapy classes. A super-bill will NOT be created upon request. SKILLS COURSE SESSION APPOINTMENTS Each session lasts 60 minutes at a predetermined time for TOTAL of 6 weeks. The sessions’ date and time are reserved for the client. CANCELLATION OF APPOINTMENTS If the client will not be able to attend the scheduled class, the client is advised to notify the therapist as soon as possible. Refunds for the class will not be issued. Contact the therapist if there are any extenuating circumstances. EMERGENCY SESSIONS If a class member does not currently have a therapist and goes into crisis an individual session will be offered. Emergency individual therapy sessions for stabilization are available on a case by case basis. The fee will be $130.00 per session. A superbill will be provided to the client. Sessions WILLNOT be submitted to the client's insurance company.

There are additional procedures that we need to have in place specific to Telehealth services. These are for your safety in case of an emergency and are as follows: You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telehealth services are not appropriate. I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please enter this person's name and contact information below. This may be the guardian/family member. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees to take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above. Client Signature indicating they understand and agree to all emergency procedures:

ESCALATION OF TREATMENT If throughout the skills course it becomes apparent that the clients’ symptoms have escalated beyond what this course can address, this service will be terminated. Clients will be directed to a higher level of care based on clinical recommendations. In this event, you will be refunded for the prorated amount for that module. COMMITMENT You are making an agreement to enroll for the entirety of the course (6 weeks). Each session is $35.00 and will be billed in total ($210.00) at the time of enrollment. You may un-enroll at any time, however, will not be refunded for the current module. Session fees are not contingent on attendance. You will not be charged for any other module(s) and will need to enroll with each module individually. Services will end with the completion of the module. To unenroll prior to the 6 weeks, please email: info@stillmovecounseling.com STILL MOVE COUNSELING, LLC FEES Payment is automatically billed per module (six weeks) and required prior to attending the class. A confirmation email will be sent. If you need any additional information please reach out to info@stillmovecounseling.com. Still Move Counseling accepts payments through credit card and checks received prior to the start date of the class. Non-Covered Services. The client is responsible for all non-covered services provided. Emergency sessions. Individual therapy sessions fee is $130.00 per session. A super bill will be provided to the client. Individual sessions will be submitted to the client's insurance company by the client. Collection services. The client is responsible for paying any additional charges related to the cost of collection (including, but not limited to, collection agency fees, returned checks, reasonable attorney’s fees and court costs) in the event that the client fails to pay the Still Move Counseling, LLC bill. Records Request. Still Move Counseling, LLC reserves the right to charge the maximum allowable charge for chart preparation, chart copies/releases, creation of letters, and completion of forms. These fees are the responsibility of the client. Payment is due prior to the information being released. The fee rate for records request is $75.00 per clinical hour. Record creation. Assessments, chart reviews, and clinical documentation preparation requests will be charged $130.00 per hour. Payment is due prior to the information being released. Subpoenas. Still Move Counseling, LLC fee for appearing in court is $3000.00 per day. Payment is due prior to the date of appearance. The client will be responsible for any additional attached attorney, collection, and legal fees. Client/Guardian initials indicating theyunderstand and agree to follow the client fee assignment.

Service charges: accumulated within 24 hoursLength of time- Provisionally Licensed Clinician, $17.50/per / Licensed Clinician$25/per10-15 minutes-$17.50/$25.00 16-30 minutes-$35.00/$50.00 31-45 minutes-$52.50/$75.00 46-60minutes-$70.00/$100.00 61-75 minutes-$87.50/$125.00 76-90 minutes-$105/$150.00 … and so on. Please note that the accumulation of time spent providing therapeutic/case management services outside of sessions may involve family members, school counselors, psychiatrists, emergency responders and hospital staff. It is a self-pay fee. Meaning, you will be responsible for the payment.

I consent to be treated by the Still Move Counseling, LLC therapist instructor that I am seeing today. I have had the opportunity to discuss any concerns regarding the proposed counseling services and treatment. I agree that all questions were answered accordingly and to my satisfaction. I understand that I may revoke this consent for treatment at any time and by doing so, I release Still Move Counseling, LLC of liability/responsibility for continued care/treatment. I have the option to withhold consent at this time or to withdraw this consent at any time, including during a skills session, without affecting the right to future care, treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. The potential benefit of Telehealth services is that I will be able to talk with a mental health staff for group psycho-education. When appropriate, I will be able to participate in group psycho-education and group processing. The potential risk of Telehealth services is that there could be a partial or complete failure of the equipment being used which could result in mental health staff’s inability to complete the mental health services. There is no permanent video orvoice recording kept of the Telehealth service’s session, unless with written permission provided by the client or guardian. All existing confidentiality protections apply. All existing laws regarding client access to mental health information and copies of mental health records apply. Dissemination of client identifiable images or information from the Telehealth interaction to researchers or other entities shall not occur without the consent of the client.By signing, I consent to Telehealth services in circumstances where it will be safer toprovide services electronically. My mental health care provider has discussed withme the information provided above. I have had an opportunity to ask questions aboutthis information, and all of my questions.