We are so happy you booked your first appointment. Enclosed you will find your new client paperwork and some important information about our office.

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1 Welcome to our practice! We are so happy you booked your first appointment. Enclosed you will find your new client paperwork and some important information about our office. You have two main things to do prior to your first appointment: 1) Please review, sign, and bring in the Consent and Privacy Policy forms to your first session. You only need to bring the actual signature pages with you. The rest of the forms are your copies to keep. 2) Go to TherapyAppointment.com and make sure to register as a new client. There are additional directions on our website to help you do this. Getting here: Our office is located at:. Parking: There is a parking lot behind our building; however, all of these spaces are reserved. You will be towed if you park here. You will need to look for on-street parking. In the evening, there is usually ample space in front of our office and on Pendleton Street, a side street that intersects with 107 West Marshall s block. During the daytime you may need to look on Pickering St and Washington St. (the main street through Middleburg). Getting into our building: Once you get to 107 W. Marshall St. go around to the left side of the building. You will see our exterior entrance. This door will take you directly into our waiting room. Going in through the front door is also an option; if you do, come all the way to the back of the building and look for the door marked Village Family Counseling. This will take you into our waiting room. Please call or us with any additional questions or concerns. We look forward to meeting you, and welcome to Village Family Counseling! Warmly, Melissa & Jill 1

2 Consent for Treatment 2016 We know that once you call for treatment, you are anxious to get going; however, we have some important information that we need you to review prior to starting. In fact, we need everyone ages 13 and older, involved in treatment, to review and sign this consent form. In addition, all guardians with legal parental rights must sign the Parental Consent for Minors. Information about your therapist I am a Licensed Clinical Social Worker in Virginia and a Certified EFT therapist. Although I share office space here at Village Family Counseling, I am an independent practitioner General overview of the process 1) Assessment Phase Our first 2-4 assessment sessions are basically a getting to know you process. In relationship therapy, you can expect these initial sessions to be a combination of joint and individual meetings. At the end of assessment, we should have a clear picture of your treatment goals, my ability to help you meet these goals, and how we will accomplish these changes. If it turns out that I am not a good fit for you, I will provide you with referrals. 2) Working Phase The working phase tends to last between sessions. This is a big range, but there is just no way to accurately predict your specific timeframe. These sessions tend to last for 55 minutes, and you can expect to have a weekly, repeating appointment time, whenever possible. 3) Consolidation and Termination Phase This phase is typically 2-4 sessions. We use this phase to solidify the changes you have made, with particular focus on how to maintain these changes in the future. Benefits and risks of therapy There is no way to guarantee your results in therapy; it s a highly personal process. We all react differently, but here are some general guidelines. Benefits of therapy can include: Significant reduction in feelings of distress, increased connection in interpersonal relationships, greater personal awareness and insight, and increased skills for managing stress and resolutions to specific problems. Adverse reactions to therapy may include: 2

3 Exacerbation of symptoms or relapse of symptoms following cessation of therapy, disillusionment with the therapeutic process, and brief periods of increased stress during the therapy process as intense emotions, memories, or conflicts are processed. Confidentiality & your medical record Your medical record is stored electronically, according to HIPAA standards, through Therapyappointment.com. It includes your attendance, payment record, notes from each session, and various other relevant health information/documents. My privacy policy outlines the handling and confidentiality of this record, but here are some important facts: In general, your health information is protected, confidential, and under your control. By law you can request access to this record. If you are in relationship therapy, you will share a joint medical record. All adult parties can access this record. Reported acts of child-abuse, being at risk of seriously harming yourself or others, and court-ordered subpoenas create confidentiality exceptions. In these situations, I may be legally obliged to disclose information from your record. Video recording, by therapist or client, requires written consent from all parties. If I should become incapacitated, either during your care or after termination, I will designate a therapist of my choosing to store and handle your medical record. Relationship therapy Relationship therapy is different from individual therapy, and this difference can be confusing. Here is a simpler way to think about it: your relationship is my client. All care is geared toward and in service of your relationship. Here are some important points: Because relationship therapy is geared towards creating safe connection, I will not knowingly continue relationship therapy with ongoing secrets. Unless alternative plans have been made, we will all meet together at each session. Please be sure to copy all involved adults on s sent to me and notify them if you call me outside of session. Transparency is key. If I have worked as your relationship therapist, I cannot become your individual therapist; however, I am happy to refer you to another therapist. Because you have a joint record, I ask for your promise not to use the information given to me during the therapy process (whether verbal or written) in any judicial setting. This includes child custody and or divorce proceedings. Communication guidelines Here is a simple breakdown of how I communicate with my clients outside of session: Emergencies: I do not have an emergency phone line; please call 911. Urgent clinical matters: Call my cell; please don t or text. Administrative issues/updates: Please send me secure through TA Running late for an appointment: You can call or text me. 3

4 I do not communicate with clients via social media, including Facebook & LinkedIn. Payment Payment is due at the time of service. I accept cash, check, and most credit cards. Alternative payment schedules and rates can be negotiated for existing clients with a financial hardship. I do not negotiate sliding scale fees for new clients. If your balance reaches $250.00, all ongoing services will be put on hold until paid. I am an out-of-network provider with all insurance companies, but with your consent, I will file your claims free of charge. You will be responsible for ensuring your information is up-to-date and any needed follow-up. Fees Initial evaluation/intake appointment: $150 Ongoing therapy: $125 per 55 minutes of therapy Phone support: pro-rated according to my hourly rate Late cancellation fee: $125 Returned check fee: $50 Legal services (testifying in court): $300/hour Copying and sending your Medical Record: Charged in accordance with VA statute/hipaa regulation Insurance will not reimburse for ancillary services or late cancel fees. Scheduling appointments and missed appointments Please use Therapyappointment.com to schedule/cancel appointments. To avoid the late cancel fee, you must cancel by 2 pm on the day prior to your appointment. I strongly recommend you sign up for appointment reminders. All clients are given one free late cancel during the course of treatment. We don t follow Loudoun County School closures for inclement weather or holidays. Early termination Termination is part of the therapy process, and we hope that it comes at the end of successful therapy. If, however, you want to end treatment early, I ask that you have at least one appointment to discuss this decision prior to terminating. Although rare, some circumstances will force me to terminate our therapy. These include: More than 3 late cancellations An account balance greater than $ which you refuse to pay Lack of improvement during therapy or non-compliance with our joint treatment plan Any threatening or criminal behavior directed towards any person or the property at VFC. If this should happen, I will attempt to discuss this with you, provide written documentation and alternative treatment referrals and resources. 4

5 NOTICE OF PRIVACY PRACTICES 2015 Your health record contains personal medical information about you, often referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how I may use and disclose your PHI and your rights to access and control your PHI. I am required to provide you with notice of my privacy practices and to abide by it s terms. I reserve the right to change the terms at any point. HOW I 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. I may disclose PHI to any other consultant only with your authorization. 2. For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount. 3. Required by Law. Under the law, I must disclose your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with HIPPA. Disclosures Without Authorization. The following disclosures are permitted by HIPAA without an authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations. These HIPPA exceptions include: 1. Child Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect. 2. Judicial and Administrative Proceedings. I 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, I 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. I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. 5. Family Involvement in Care. I 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, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. 7. Law Enforcement. I 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, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises. 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, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information. 5

6 10. Public Safety. I may 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. Research and Training PHI may only be disclosed for research purposes after a special approval process or with your authorization. Training and supervision disclosures require your authorization. 12. Verbal Permission. I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission. Disclosures With 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. 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 at Generations Family Counseling. 1. Right of Access to Inspect and Copy. You have the right to inspect and copy PHI that is maintained in your medical record. Your medical record is currently stored electronically. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. You may request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person 2. Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. Right to an Accounting of Disclosures. You have the right to request an accounting of PHI disclosures. 3. Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the PHI pertains to a health care item or service that you paid for out of pocket. In that case, I am required to honor your request for a restriction. 4. Right to Request Confidential Communication. You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. I will not ask you for an explanation of why you are making the request. 5. Breach Notification. If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself. 6. Right to a Copy of this Notice. You have the right to a copy of this notice. Complaints If you believe I have violated your privacy rights, you have the right to file a complaint in writing to your therapist or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W.Washington, D.C or by calling (202) I will not retaliate against you for filing a complaint. 6

7 Consent for Treatment 2016 By signing below, I acknowledge that I am at least 18 years of age, and I give my full consent to participate and receive mental health treatment. Furthermore, I certify that: I have read the Consent to Treatment Form and agree to abide by the policies contained within. I understand my first 2-4 sessions are used for assessment, and there is a possibility that my therapist may need to refer me to another provider. I understand this consent will go into effect upon the signing of this form, and that I am financially responsible for my treatment. I am aware that I can withdraw my consent at any point, and I understand the circumstances under which my therapist may terminate treatment. Should I choose to file for insurance reimbursement, I give permission for my therapist to release any relevant protected health information to my insurance company. I understand that without this consent, I cannot use insurance benefits Printed Name of financially responsible party DOB Signature of financially responsible party Printed Name of financially responsible party DOB Signature of financially responsible party Therapist Name & Signature 7

8 Privacy Practices Acknowledgement By signing below, I acknowledge that I have been provided a copy of the current Privacy Practices Notice I understand these policies may change in the future, and that I will be provided the new copy should this occur. Your name (please print): Your Signature Your name (please print): Your Signature ****In order to use text messaging for appointments, HIPAA regulations require that you must consent to this in writing. By initialing below, you consent to using text message with the full understanding that I cannot guarantee your confidentiality. Initial here Initial here 8

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