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You must be 18 years of age or older to complete this form.

Therapist

Client Information

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Emergency Contact

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Phone
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Email
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( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Online Video Therapy Agreement

PLEASE READ CAREFULLY

It is important that you, as my client, read and understand the following:

1) To maintain privacy and your confidentiality I will only conduct video sessions from a secure and confidential area (with the door closed and a sound blocker on).


2) There are precautions that you can take to increase confidentiality, including:                   

a) Ensuring that you are online in a private room/area with the door closed and, if possible, using some type of sound blocking device.

b )When possible, connect to the Internet directly (as opposed to using public WiFi; this also helps with transmission).

c) Make sure to log off, not just disconnect from the call when the session is over.

3) Make the same commitment to your online session that you would to an in-office appointment.

a) Don't be late.

b) Limit distractions - turn off cell phones; avoid 'split screens.' Explain to others that you are unavailable for the next hour. Unless we are conducting couples therapy there should be no one else in the room with you during our session.

c) Have your computer on a firm surface and sit on a comfortable sofa/chair or at a desk if possible.

d) Check the audio/visual in the 'preferences' each time before a session so that you can see what I am seeing and that the audio level is sufficient.

4) Similar to an in-office appointment, an online therapy session is subject to a 24-hour cancellation or no-show fee. If you fail to cancel a scheduled appointment, we cannot use this time for another client and therefore you will be billed $50.00 for the missed appointment. Our late cancel and no-show policy can be reviewed with your therapist during your initial consultation or first session.


5) Online counseling can be useful and helpful for most, but it is not appropriate for everyone. This is especially true if you are in need of immediate medical or psychiatric help. If it is determined during our sessions that your issues are not appropriate for online counseling, you will be given information on resources in your area to contact.


6) We do not provide assessments, paperwork or letters for disability claims or legal issues (including divorce/custody issues, DUI, or lawsuits). We do not respond to any third-party solicitations or sales calls.


7) Our self-pay rates are pay per-session and the current rates are listed on our website. Payment for each session is expected on the date of service, following your session. You are required to enter a credit or debit card into your CounSol account to cover your therapy session fees. You will be advised in advance of any changes to our fees. EFFECTIVE JANUARY 1, 2022, counselors, therapists and other health care providers will be required by law to give uninsured and self-pay patients and clients a good faith estimate of costs for services that they offer, when scheduling care or when the client requests an estimate. Your therapist will provide and review the estimate with you prior to your first appointment or upon request.

***If you choose to use health insurance for payment it must be a plan that your individual therapist accepts. Not all the therapists at eTalkTherapy accept insurance and plans do vary. Please contact your insurance provider prior to your first appointment to learn what behavioral health services your insurance covers and whether you will be responsible for a co-pay, deductible or co-insurance for your online therapy sessions. When using insurance you will be responsible for any co pays or deductible/coinsurance payments that your insurance requires. You will be required to enter a credit or debit or HSA card into your CounSol account to cover any fees associated with your insurance plan.  Please ask your therapist for details or if you have any questions. If you choose to no longer use insurance you can always select one of our self-payment options.


8)I have read the Video Therapy Agreement. I understand and agree to comply with the policies as they are described and acknowledge receipt of this agreement and attest that I am at least 18 years of age or older.

( Type Full Name )
( Full Name )
Agreement for Services and Notice of Practice’s Policies to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

Uses and Disclosure for Treatment, Payment and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

PHI refers to information in your health record that could identify you

Treatment and health care options: treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as family physician or another mental health clinician. Health care operations are activities that relate to the performance and operation of the practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management and coordination of care.

Use applies to only activities within the practice such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you.

Disclosure applies to activities outside of the practice such as releasing, transferring, or providing access to information about you and other parties.

Please note: Certain Insurance Companies may audit client records for the purpose of ensuring therapist compliance with
insurance record keeping and treatment standards.

Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment and health care operations when you sign a separate authorization allowing us to do so. We will also need to obtain a separate authorization before releasing therapy notes or letters highlighting your treatment. These notes are given a greater deal of protection than PHI.

You may revoke all such authorizations of PHI or therapy notes at any time, provided each revoking is in writing. You may not revoke an authorization to the extent 1) we have relied on authorization; 2) if the authorization was obtained as a condition of insurance coverage and the law provides insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

Insurance: Certain Insurance Companies may audit client records for the purpose of ensuring therapist compliance with
insurance record keeping and treatment standards.

Child Abuse: If we have reasonable cause, on the basis of our professional judgment to suspect child abuse of children with whom we come in contact in our professional capacity, we are required by law to report this to the Pennsylvania Department of Public Welfare.

Adult or Domestic Abuse: If we have reasonable cause to believe an adult is in need of protective services (regarding abuse, neglect, exploitation, or abandonment) we may report such to a local agency which provides protective services.

Litigation Limitation: You must disclose prior to the beginning of treatment any legal issues that you may be already involved in. Due to the sensitive nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which are of a confidential nature, it is agreed that should there be legal proceedings resulting from, but not limited to, a client's divorce or custody disputes, work injuries, disability claims, lawsuits, etc., neither you (client) nor your attorney, nor anyone else acting on your behalf contact your therapist or any other party associated with eTalkTherapy, LLC to testify in court or at any other proceedings, nor will a disclosure of the therapy records be released for such proceedings with the following exception:

A Court Order, issued by a judge or magistrate, may require eTalkTherapy, LLC staff to release information
contained in client records and/or require your therapist to testify in a court hearing. This will still require appropriate consent, which means a HIPAA-compliant authorization will be required. In most legal proceedings,
you have the right to prevent release of information about your treatment. However, if a Judge issues a Court Order,
your records can be released without your permission. In some proceedings involving child custody and those in
which your emotional condition is an important issue, a judge may order therapist testimony if he/she determines that it is necessary.

Serious Threat to Health or Safety: If you express a serious threat or intent to kill or seriously injure yourself or an identified or readily identifiable person or group of people and we determine that you are likely to carry out the threat, we must take reasonable measures to prevent harm. Reasonable measures may include directly advising a potential victim of threat or intent (Duty to Warn). For this purpose, we may also contact the person whose name you have provided on the biographical sheet and the necessary authorities to ensure safety.

If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required
to report this information to the authorities responsible for ensuring safety. If a client is threatening serious
bodily harm to another, protective actions are mandated. These actions may include notifying the potential
victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm
himself/herself, a safety plan will need to be developed to prevent serious harm. In rare cases, it will be
necessary to seek hospitalization for him/her or to contact family members or others who can help provide
protection.

Emergency Procedures: If you need to contact your therapist between sessions, please send an email through the CounSol portal. Your therapist checks his/her messages several times during the day, unless he/she is out of town at which other arrangements/options will be made available to you. If an emergency situation arises, indicate it clearly in your message, and if you need help right away, call 911 or go the nearest emergency room or call one of the several Help Lines posted on our website.

PAYMENT INFORMATION

Insurance: If you choose to use health insurance for payment it must be a plan that your individual therapist accepts. Not all the therapists at eTalkTherapy. LLC accept insurance and plans do vary. Please contact your insurance provider prior to your first appointment to learn what behavioral health services your insurance covers and whether you will be responsible for a co-pay, deductible or co-insurance for your therapy sessions. When using insurance you will be responsible for any co pays or deductible/coinsurance payments that your insurance requires. You will be required to enter a credit or debit or HSA card in your CounSol account to cover any costs associated with your plan. Please ask your therapist for details or if you have any questions.

Updates: It your responsibility to make sure all the information entered into your CounSol profile is updated as needed and current. This includes your name, address, phone number, email address and emergency contact information. Additionally, please update your payment information if anything changes with your card or bank. eTalkTherapy, LLC and your therapist will not be responsible for outdated or incorrect information on your profile.

Privacy: It is important that you follow secure steps to ensure your session is private. Be in a private area with the door closed and, if possible, have a sound blocking (white noise) device running during your session. Always use a private internet connection, never use a public WIFI connection. Never share your login information with anyone. When possible, always be sure your internet protection is updated and working. 

Self-Payment: Our-self payment options are pay per session and the current fees are posted on our website. Payment is due at the time services are rendered. There are no subscriptions or advanced payments expected or required. EFFECTIVE JANUARY 1, 2022, counselors, therapists and other health care providers will be required by law to give uninsured and self-pay patients and clients a good faith estimate of costs for services that they offer, when scheduling care or when the client requests an estimate. Your therapist will provide and review the estimate with you prior to your first appointment or upon request.

Cancellation Policy: If you fail to cancel a scheduled appointment, we cannot use this time for another client and therefore you will be billed $50.00 for the missed appointment. $50.00 is charged for missed appointments for cancellations with less than a 24-hour notice unless it is due to an emergency. The credit card that we will have on file for you will be charged if you fail to cancel your appointment without advanced notice.

Termination: As set forth, after the first few sessions, your therapist will assess if he/she can be of benefit to you. eTalkTherapy does not accept clients who they believe they cannot help. In such a case, you will be given a number of referrals who you can contact. If at any point during therapy your therapist assesses that he/she is not effective in helping you reach the therapeutic goals or that you appear to be uncommitted to the therapeutic process he/she is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, he/she will give you a number of referrals that may be of help to you. You have the right to terminate therapy at any time. If you choose to do so, and if appropriate, your therapist will offer to provide you with names of other qualified professionals or resources.

The Process and Scope of Therapy: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Therapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc, or experiencing anxiety, depression, insomnia, etc.

Your therapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Therapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but it can be slow and even frustrating. There are no guarantees that therapy will yield positive or intended results.

During the course of therapy, your therapist is likely to draw on various counseling approaches according to the issue that is being treated and his/her assessment of what will best benefit you. Your therapist does not provide medication or prescription recommendations nor legal advice, as these activities do not fall within the scope of a counseling practice. Your therapist will not write letters for legal matters or disputes or disability claims (see above).

There may be additional disclosures of PHI that we are required or permitted by law to make without your consent or authorization, however, the disclosures listed above are the most common.

Client's Rights and Practice's Duties

Client's Rights:

Right to request restrictions: You have the right to request restrictions on certain uses and disclosures of PHI about you. However, we are not required to agree to a restriction you request.

Right to receive confidential communications by alternative means and at alternative locations: You have the right to receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing us. Upon your request, we will discuss with you the details of the amendment process.

Right to amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

Right to an accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this notice). Upon your request, we will discuss with you the details of the accounting process.

Right to a paper copy: You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to receive this notice electronically.

Right to a Good Faith Estimate: EFFECTIVE JANUARY 1, 2022, counselors, therapists and other health care providers will be required by law to give uninsured and self-pay patients and clients a good faith estimate of costs for services that they offer, when scheduling care or when the client requests an estimate. Your therapist will provide and review the estimate with you prior to your first appointment or upon request.

Health Care Provider Duties

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

If we revise our policies and procedures, we will notify you.

Questions and Complaints

If you have questions about this notice, disagree with a decision made about access to your record, or have other concerns about your privacy rights, you may contact our office.

If you believe that your privacy rights have been violated and wish to file a complaint with the office, you may send your written complaint to:

eTalkTherapy, LLC.

PO Box 234

Wexford, PA 15090

etalktherapy@gmail.com

You may also send a written complaint to the Secretary of the US Department of Health and Human Services. The office can provide you with the appropriate address upon request.

You have specific privacy rights under the privacy rule. We will not retaliate against you for exercising your right to file a complaint.

Effective Date, Restrictions and Changes to Privacy Rule

This notice is effective immediately and its contents may change without notice.

I acknowledge that I have received, read and understand the Agreement for Services and Notice of the Practice's Policies. I attest that I am at least 18 years of age or older.

( Type Full Name )
( Full Name )