Client Information & Consent

Thank you for choosing me to walk with you on your journey; it is an honor.  Please read this information carefully; it contains vital information regarding my professional services, my practice, and what we should expect from each other on our journey together. 

Therapy’s purpose & how to attain a more fulfilling life:  It can be incredibly challenging to reach out for help; however, therapy can be very advantageous in addressing numerous problems by providing new ways of communication within relationships, establishing healthy boundaries, creating stronger connections with loved ones, improving self-esteem, manifesting inner peace & hope, and fostering coping skills to decrease depression, anxiety, anger, mood swings.  I engage with all clients respectfully and collaboratively in an honest, open, and mindful manner, aware of difficulties or challenges they may encounter while maintaining a professional relationship.

What you should expect from therapy:  Sessions may confront clients, causing them to question their beliefs or values, or something from their past may be brought up that triggers them.  This may cause their symptoms or emotional encounters to intensify briefly, which could be difficult for the client.  Often, therapy will challenge the client to challenge old ways of thinking or recall traumatic events.  However, the therapeutic process will help the client process these emotions if they arise healthily.  Sessions can occur individually, as a couple, or in a family setting.

My primary therapeutic approach and general intervention strategies:  My preferred theories and techniques included Satir, Choice Theory, Existentialism, Cognitive Behavior Therapy, and Dialectical Therapy.  I employ therapeutic modalities constructed for my client and their unique needs.  I believe everyone has an inner child who desires to be loved and cared for, and everyone can change their lives by changing how they think and perceive things.  My focus is depression, anxiety, sexual trauma, intimate partner violence, mental illness such as bipolar disorder and schizophrenia, and substance abuse. 

Scheduling and communication: Once established as a client, you may schedule online, if you wish, via an online scheduling procedure.  You may be sent an automated text reminder of your appointment time. Emails, texting, social media, and similar forms of communication have some advantages but are inherently complex to secure.  Any information transmitted through those formats can compromise your privacy.  Please do not use emails, faxes, or texting for emergencies.

Late cancellations or no-show policy:  Your session is reserved for you and is typically 45-60 minutes.  Therefore, cancellations must be made at least 24 hours in advance.  Failure to do so will result in a $25 late cancellation or no-show fee. Regular attendance is essential to your treatment’s effectiveness and continuity of care.

Emergency contact between sessions:  I am happy to provide therapy hours in the evenings and on weekends. However, I am incredibly protective of those hours, representing time beyond standard daytime working hours for myself and my clients.  If there are several missed evening/weekend appointments, I reserve the right to restrict scheduling to weekday hours.  However, please go to the nearest emergency room and dial 911 in an emergency or crisis.

Fees for individual, couple, and family sessions:  

• The first session (intake): $100

• Second and subsequent sessions: $80

• Couple & family session – intake: $100

• Couple & family session – second and subsequent sessions: $80

• Legal Action: $200 per hour 

• Rate Cancel & No Show fee $25 per occurrence

RESPONSIBILITY:  The client or legal guardian of a minor is responsible for the payment of services.  When a third party, such as divorced parents or divorced or separated spouses, fails to make timely payments, payments will be expected from the client and legal Guardian in the case of a minor child.  

Insurance:  I do not accept insurance.

Limits of confidentiality, what I am required to report, & duty to warn:  Texas does not have a duty to warn.  If someone discloses a plan or intent to take harmful, dangerous, or criminal action against themself or someone else, I may have a responsibility to report their plan or intent.  Furthermore, according to rule §801.48:

1.     If I am aware of or suspect any abuse (sexual, emotional, physical, or financial) or neglect of a child, elderly individual, or person with disabilities, legally, I am required to report the abuse to the appropriate protective services.

2.     If I think that a client poses an inevitable and imminent danger of violence or harm to anyone, I can notify the authorities.

3.     If you disclose intent to harm yourself, I am ethically bound to help keep you safe, which may include informing others who can help.

4. If my testimony is ordered by a judge or if you raise your psychological state as an issue in a legal proceeding, I may be required to disclose confidential information to the court.

Confidentiality:  My clinical record is comprised of clinical notes, treatment plans, and other documents that will be maintained on your behalf for clinical and business purposes.  You must submit a written request if you require a copy of my records.  Texas law stipulates that I reserve the right to furnish a treatment summary instead of the records and decline to supply a copy of the record under specific considerations.  However, I can provide another provider with a copy of the requested record.  Your records will be maintained for seven years upon termination of treatment and then be destroyed in a HIPAA-compliant manner.  If the client is a minor, records will be retained for ten years after the minor’s eighteenth birthday.  Copies of records may incur administrative fees.    

Limits of confidentiality with minors: To provide the best therapeutic environment for adolescents and establish a healthy therapeutic bond in which the adolescent has an opportunity for successful treatment, a trusting environment, and privacy, my policy is to provide a waiver of the right to the child’s records or information.  This policy ensures the minor has a right to privacy and the freedom to speak without retaliation, just as an adult would.  The law stipulates parents or legal guardians may not have rights to that information regardless of their signed consent disclosure of suicidal ideation, substance or alcohol abuse, sexual, physical, or emotional abuse, or if the disclosure of certain information to a parent or guardian discussed during treatment may be harmful to the adolescent.

My responsibilities and your rights during therapy: 

1.     You have the right to question any technique used during our session, and I will describe it to you in terms so that you understand my methods and techniques. 

2.     You have the right to choose not to receive treatment.  I can provide additional resources or refer you to another qualified therapist.   

3.     You have the right to terminate therapy without any moral, legal, or financial obligations except those fees already accrued.  Please allow me the opportunity before termination of treatment to assist you with discharge planning and continuity of care. 

4.     You have the right to expect that I will maintain professional and ethical boundaries by not engaging in personal, financial, or other professional relationships with you, which could significantly forfeit the progress made from our therapeutic relationship. 

5.     Therapy involves a connection between a therapist and their clients.  As your therapist, I will continue to broaden my knowledge, deepen my skill set, and commit to doing my best to provide a beneficial therapeutic environment for you.

Circumstances for a referral: If you feel you have not made progress, plateaued, cannot afford treatment, have become noncompliant with treatment, or your needs have changed, I am happy to provide you with a referral to another provider.  Sometimes, we are simply not compatible, which is okay, too.  I do not take that personally; I only ask for your honesty.    

If you wish to file a complaint with the licensing board:  You may call the Texas Behavioral Health Executive Council at (512) 305-7700, 800-821-3205, or visit https://www.bhec.texas.gov/discipline-and-complaints/index.html for more information. 

Your Rights

You have rights, and I have a responsibility to help ensure you are aware of your rights as they pertain to your protected health information (PHI).   

• Clinical record:  You can ask to view or obtain a copy of your clinical record.  I will review your request and respond, typically within 15 business days of your request.  Upon approval, a reasonable, cost-based fee may be incurred.  However, in some circumstances, your request may be denied, in which details will be provided in writing, and you may have the right to ask another professional to review our decision.  

• Amend inaccuracies in your clinical record: You have the right to request inaccuracies be corrected if your PHI is inaccurate or lacking.  I have the right to I have the right to deny your request in writing within 60 days.

• Request confidential communications: You have the right to ask that I contact you in a particular manner, such as via home or cell phone, email or text message, or send mail to another address.  I will attempt to accommodate reasonable requests.   

• Ask me to restrict what I use or distribute:  You can ask me not to use or share certain health information for treatment, payment, or my operations.  I am not required to agree to your request, and I may deny it if it affects your treatment.

• Obtain a list of whom your information has been shared: You can ask for an accounting of the disclosures of your PHI for six years before the date you ask, which will include all disclosures except those about treatment, payment, health care operations, and certain other disclosures such as any you asked us to make.  You will be provided one accounting per year free of charge, and each additional accounting will be charged at a reasonable, cost-based fee.

• Receive the privacy notice: You can ask for a copy anytime.

• Choose someone to act on your behalf: If you become incapacitated and someone has been granted Medical Power of Attorney or is your legal guardian, they can exercise your rights and make choices regarding your health information.  

• File a complaint if you are violated:  If you would like additional information or feel I have violated your rights, you can file a formal, written complaint without fear of retaliation.  You may do so with the following entities:

The U.S. Department of Health and Human Services Office of the Attorney General

Office of Civil Rights PO Box 12548

200 Independence Ave. S.W. Austin, TX 78711-2548

Washington, D.C. 20201

Texas Department of State Health Services

Management & Investigation Section

PO Box 141369

Austin, TX 78714

Your Choices

You have the right to tell me what information I can share regarding your health information.  In these cases, you have the right to tell me to:

• Share information with your friends & family or others involved in your care

• Share information in an emergency

Uses and Disclosures for PHI

Your health information is typically utilized in the following ways:

• To provide care: I use your PHI to treat you and share it with other treating professionals to provide continuity of care.

• Running my practice: I utilize and disclose your PHI to run my practice, improve your care, help you progress in treatment, and contact you.

• Receive payment for your services: I utilize and disclose your PHI to bill your insurance to receive payment from third-party vendors.      

• Legal compliance

  • If I believe that a child’s physical or mental health or welfare has been adversely affected by abuse or neglect or that a child has been abused or neglected or may be abused or neglected;

  • If I believe that an elderly or disabled person is the victim of abuse, neglect, or exploitation;

  • If I believe that an individual is the victim of abuse, neglect, illegal, unprofessional, or unethical conduct in an inpatient mental health facility, a chemical dependency treatment facility, or a hospital supplying acute rehabilitation services;

  • If I believe a mental health provider engaged in sexual exploitation against a client;  

  • If law enforcement instructs me to disclose information regarding the treatment of an individual who is a registered sex offender.

I may receive a legal request to disclose your PHI:

• Respond to lawsuits and legal actions

• For government functions, such as national security

• For law enforcement

• Court order or subpoena

My Responsibilities:  I must preserve the privacy and security of your PHI within the constraints of the law and will notify you immediately that your privacy may have been compromised in a breach.  Furthermore, I am obligated to follow the privacy practices depicted in this notice and provide a copy to you.  Your PHI will not be shared in a manner other than as described here unless you are notified by you in writing, which you may revoke at any time.

CHANGES TO THE TERMS OF THIS NOTICE

The conditions of this notice can change and will be relevant to all PHI related to you.  A new notice will be accessible upon request.