GOALS OF COUNSELING RISKS/BENEFITS OF COUNSELING

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1 1 Welcome to. This document contains important information about my professional services and business policies. Attached is also a summary of information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in therapy or as a parent of a child you are consenting for therapy, you (or your child) have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you and want to inform you of them below. These rights and responsibilities are described in the following sections as well as my business policies. GOALS OF COUNSELING There can be many goals for the counseling relationship. Some of these will be long-term goals such as improving the quality of your life, learning to respond to life s stressors in a healthy way, mindfulness and insight. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior and/or decreasing/ending negative ways of coping. Whatever the goals for counseling, they will be set by the client and/or by the parent(s) or guardian(s), according to what the client and/or the parent(s) want their child to work on in counseling. I may make suggestions on how to reach that goal but the client decides what they want to address. RISKS/BENEFITS OF COUNSELING Therapy 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 and that is part of the process. Progress may happen slowly. In order to be most successful, you will have to work on things we discuss outside of sessions. This requires a very active effort on your part, along with being committed to the process and showing up consistently and/or bringing your child consistently. However, there are many benefits to therapy. Therapy can help you develop healthier ways of handling various situations, reduce symptoms of mental health problems, gain insight into your behavior to

2 2 make the appropriate changes, learn to live in the present and many other advantages. APPOINTMENTS Appointments will ordinarily be minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancelation fee. In addition, you are responsible for coming to your session on time, if you are late, your appointment will still need to end on time. CONFIDENTIALITY As your therapist, I will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. I may consult with a supervisor or other professional(s) in order to give you the best service. In the event that I consult with another therapist, no identifying information such as your name would be released. As a license therapist, I am required by law to report and release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly for the safety reasons. Under North Carolina law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include: 1.) Warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2.) Notifying a law enforcement officer 3.) Seeking your hospitalization (if appropriate)

3 3 By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or law enforcement officer, whether you are a minor or an adult. If I receive a court order or subpoena, I may be required to release some information. In such a case, I will consult with other professionals and limit the release to only what is necessary by law. If you are using insurance as your form of payment, you should be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information, which will become part of the insurance company files. COURT PROCEEDINGS: It is my policy that I do not participate in court proceedings voluntarily. If I am subpoenaed, you are responsible for my hourly rate of $130, beginning at my arrival to court and when I leave court. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment CONFIDENTIALITY & SOCIAL MEDIA As the owner of it is my policy that I do not accept friend request on Facebook from clients. I also do not provide online counseling due to its limitations on privacy and confidentiality. I do have a business Facebook page that is viewable to the public. It is your choice to choose to Like the page. If you comment in a way that reveals that you are a client, please understand that our therapeutic relationship is no longer confidential. I will continue to uphold confidentiality on my end by law. It is also important to note that I will not engage in public discourse or address therapy concerns online (via Facebook business page). Questions or concerns should be addressed in my office during our time together. RECORD KEEPING As your therapist, I will keep records of your counseling sessions and a treatment plan, which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity of service. They will not be shared except with respect to the

4 4 limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information, which specifies what information is to be released and to whom. It is important to note that although parents/guardians may legally exercise the right to access their child s mental health records. HIPPA allows the license professional provider to exercise professional judgment in denying access to those records, 45 C.F.R (g)(3)(ii)(c). In general, records will be kept in a lock cabinet in my office for at least seven years but may be kept for longer. PROFESSIONAL FEES You are responsible for paying your fee at the time of your session unless prior arrangements have been made. Payment must be made by check, cash or debit/credit. If you choose debit or credit, please note a 3% transaction fee will be charged to cover the use of the PayPal swipe card. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required. Fees are non-negotiable. **Please note, fees are subject to change at counselor s discretion. Initial Counseling/History Taking, 50 minutes (Intake) $140 Psychotherapy 45 minutes (Regular) $130 EMDR Psychotherapy 75 minutes (Trauma Therapy) $160 INSURANCE If you have a health insurance policy, it will usually provide some or full coverage for mental health treatment. With your permission, I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information, which will become part of the insurance company files. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

5 5 In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover counseling fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee to be covered by the patient. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. If I am not a participating provider for your insurance plan, I 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. If you prefer to use a participating provider, I will refer you to a colleague. EMERGENCY CONTACTS Sometimes I am not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take at least 24hrs on non-urgent matters. If you feel you cannot wait for a return call or you are in an emergency or crisis situation, here are some 24-Hour Access and Crisis Telephone Contacts: 911 Emergency Number Coastal Care-Local Number (910) , Toll Free (1-866) Hour Mobile Response Team/Onslow County/Carteret/Recovery Innovations (910) Hour Walk In Crisis and Psychiatric Aftercare Center215 Memorial Dr., Building A Jacksonville, NC (910)

6 6 CONSENT TO COUNSELING I have read this Informed Consent Agreement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand and agree to it. I understand the limits to confidentiality required by law. I consent to the use of a diagnosis in billing and to the release of that information and other information necessary to complete the billing process. I agree to pay the fee of $ per min session, whether through cash, check, credit/debit or be billed through my insurance. I understand my rights and responsibilities as a client and my therapist's responsibilities to me and/or to my child. I agree to undertake therapy with Hermeisha R. Hopson, LCSW and/or allow her to provide therapy for my child. I know I can end therapy at any time I wish, and that I can refuse any requests or suggestions made by Hermeisha R. Hopson, LCSW. I am over the age of thirteen. Client Name (Print): Client Signature (or Parent/Guardian): Date: Witness: Date: =============================================================== ===============================================================