Privacy & Policy

Informed Consent and Privacy Policy

Information Regarding Counseling Rates 

$120 per 50 min. 

$150 per 50 min. family session 

$150 per 60 min. Emotional Wellness Screening

Court Appearance 

$500 per appearance. (Flat cost for travel, administration preparation and arrival). Fee must be paid prior to court appearance.

$120 per hour in court with or without testimony    Additional fees may accrue if court appearance is outside of Jacksonville, Florida

Payment  Payment may be made with cash or paid online through our website or through your secure client portal. Session payment is due after session takes place. 

 A missed appointment fee of $50 will be charged for no shows without a call within 24 hours from the date and time of your scheduled appointment.

Home and school visits may be available depending on the availability of the counselor to provide service. An additional charge of $50 shall be added if scheduling a school or home visit.

Out of Network?

You may be able to receive reimbursement from your health insurance company. Some clients are allowed to pay me directly for the full cost of the session and then receive a portion of the cost back paid by their insurance company. Contact your insurance company to see if you can see me as an "out of network" provider and be sure to ask them if and how much they will reimburse you for the services that you received with me. 

  You may also consider using your Health Savings Account (HSA) if you are eligible to receive reimbursement (at a pre-tax rate) for your sessions. Contact your HSA representative to ensure that this is an eligible expense. 

  It is your responsibility to ensure that you contact your insurance company in advance to determine if you are eligible to receive reimbursement from them.

 We do our best to verify your benefits in advance but final session fee is determined by the claims department of your insurance company.  You may have additional fees to pay if your insurance company should deny all or partial payment for your session.

 Probono Program We offer a limited number of probono appointments reserved exclusively for clients who can not afford to pay.  We accept clients into our probono program based on counselor availability to accept new probono clients.   Only individual sessions are covered in our probono program.  Any other requested services (court appearances, school visits, etc... are not included in our pro bono program).

 Informed Consent

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.

Decision to Meet Face-to-Face

We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.

If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate.

Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, [my other staff] and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement. 

·         You will only keep your in-person appointment if you are symptom free. ___

·         You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth.  If you wish to cancel for this reason, I won’t charge you our normal cancellation fee. __

·         You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time. ___

·         You will wash your hands or use alcohol-based hand sanitizer when you enter the building. ___

·         You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.___

·         You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or staff]. ___

·         You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. ___

·         If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols. ___

·         You will take steps between appointments to minimize your exposure to COVID. ___

·         If you have a job that exposes you to other people who are infected, you will immediately let me [and my staff] know. ___

·         If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me [and my staff] know. ___

·         If a resident of your home tests positive for the infection, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth.___

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My Commitment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts.

If You or I Are Sick

You understand that I am committed to keeping you, me, [my staff] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my office staff] believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate. 

If I [or my staff] test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits.  By signing this form, you are agreeing that I may do so without an additional signed release.

 Informed Consent

This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.

 

I have the option to withdraw this consent at any time by informing my counselor in writing, stating that I am withdrawing consent to participate.

I may be referred for more intensive services if my mental health functioning becomes severely impaired.

Services will be terminated or counseling sessions will not begin until payment is made.

Additional fees will be charged if counselor is requested to appear in court on my behalf.  

 

For Online Counseling Services:

I understand that:

The potential risk of private online counseling services is that there could be a partial or complete failure of the equipment being used which could result in counselor's inability to complete the evaluation or mental health services.

There is no permanent video or voice recording kept of the private online counseling session.

All existing confidentiality protections apply.

All existing laws regarding client access to private online counseling information and copies of private online counseling records apply.

Dissemination of client identifiable images or information from the private online counseling interaction to other entities shall not occur without the consent of the client.

Services will be terminated if I fail to maintain a confidential environment while participating in my private online counseling sessions.

I must inform my counselor if I move out of state so that I can be referred to another counselor.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

Get a copy of your paper or electronic counseling record.

Correct your paper or electronic counseling record.

Request confidential communication.

Ask us to limit the information we share.

Get a list of those with whom we've shared your information.

Get a copy of this privacy notice.

Choose someone to act for you.

File a complaint if you believe your privacy rights have been violated.

Our Uses and Disclosures

We may use and share your information as we:

Run our organization.

Bill for your services.

Help with public health and safety issues.

Comply with the law.

Respond to lawsuits and legal actions.

If you pose a threat to yourself or others.

If information regarding child abuse or neglect is reported.

Service Effectiveness

I understand that counseling may lead to improvements with problems or that no improvements may take place.  I further understand that I must use and implement the suggestions and techniques that I receive to see positive changes take place.  I understand that behavior/circumstances sometimes gets worse before getting better.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your counseling record.

You can ask to see or get an electronic or paper copy of your counseling record and other health information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your counseling record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications.

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say "yes" to all reasonable requests.

Ask us to limit what we use or share.

You can ask us not to use or share certain health information for counseling, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.

Get a list of those with whom we've shared information.

Get a copy of this privacy notice.

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care. 

Share information in a disaster relief situation.

Include your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you with your permission.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your counseling services.

Bill for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues.

We can share health information about you for certain situations such as:

Preventing disease.

Reporting adverse reactions to medications.

Reporting suspected abuse, neglect, or domestic violence.

Preventing or reducing a serious threat to anyone's health or safety.

Comply with the law.

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Notice Effective January 2018. 

Last Updated: Updated February 12, 2020

Contact Me