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Terms and Policy

Privacy Policy
NOTICE OF PRIVACY PRACTICES

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

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

For health oversight activities, including audits and investigations.

For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

For law enforcement purposes, including reporting crimes occurring on my premises.

To coroners or medical examiners, when such individuals are performing duties authorized by law.

For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on January 1, 2011

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
( Type Full Name )
Informed Consent for Treatment
Permission for Treatment

In presenting myself (and/or my child(ren)) for diagnosis and treatment, I voluntarily consent to the rendering of counseling services provided by Burgess Counseling and Consulting, LLC. I acknowledge no guarantees have been made to me as to the effect of treatment on my condition or relationship. I acknowledge I am responsible for all reasonable changes in connection with care and treatment. I have read this statement and acknowledge that I understand it.

This document contains important information about Burgess Counseling and Consulting, LLC privacy policies and business policies. Although therapy 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, before or at any time in the future.

ABOUT THERAPY

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 psychotherapy, you 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, your Therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
I, (hereinafter "Client") hereby acknowledge that I have voluntarily entered Psychotherapy with Nicole Burgess LMFT (A.K.A. Therapist) at Burgess Counseling and Consulting, LLC for an at will period, which either party can terminate with 48 hours' notice. I freely consent to such treatment of my free will.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it and research indicates it often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.

But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, Client will have to work on things we discuss outside of sessions. I, Client, am aware that while Psychotherapy modalities can produce benefit for many, and though it is not guaranteed, it can also produce unexpected changes since occasionally people may decide to begin or end relationships or professional contacts or even employment. No one can predict changes, outcomes or successful rates, which vary for each person. Therapist has an ethical responsibility to ensure Client understands that therapy doesn't always work, that clients may feel worse before they feel better, that relationships may change, etc. This issue is particularly pertinent for clients of a different culture.

I, Client, fully accept and assume all risks whether before, during or after completion of services. These include without limitation, risk of physical injury, mental injury, emotional distress, trauma, death, and contact with other participants and the effects of weather, including temperature, power outages or other conditions at the place where services are rendered or elsewhere.
As lawful consideration for being a client and participating in services, I agree that I, my heirs, guardians, legal representatives and assignees will not make any claims against, law suits, attach the property of or prosecute Burgess Counseling and Consulting, LLC/Nicole Burgess LMFT. In addition, I hereby release, acquit, and forever discharge Burgess Counseling and Consulting, LLC/Nicole Burgess LMFT, of and from all manner of actions, cause of action, suits, debts, property attachments, covenants, contracts, controversies, agreements, promises, claims and demands whatsoever that I ever had, now have, or which any personal representative, successor, heir or assignees of mine hereafter can, shall or may have against Burgess Counseling and Consulting, LLC/Nicole Burgess LMFT, by reason of any injury, damages or misconduct resulting from my participation in therapy modalities with Therapist. This Agreement includes the waiver and discharge of any and all liabilities, damages and claims, including those not known; arising out of any contact the client has with Therapist. The Agreement terms will not be affected by any facts, which may later appear, come up, arise or become known.

This "Informed Consent of Treatment", also referred to as this Agreement and/or Document, consisting of seven (7) pages is a complete and final version of the terms of this Agreement. There have been no inducements, representations or promises made to Client other than those set forth herein.

APPOINTMENTS & FEES

Therapy sessions consist of a 50-minute hour. The Therapist's fee is $180 per session whether Face-to-Face, phone or video conference (online). It will also be stated on your scheduled appointment on your client portal Counsol.com. Payment for professional services is due in full at the time of services are rendered. If I encounter a problem with the payment of fees, I shall discuss it with the therapist immediately.

All appointments need to be scheduled in advance with the Therapist. Client knows that he/she must call or log into Portal (outside regular business hours) to cancel an appointment at least 48 hours before the time of the appointment. If Client does not cancel or does not show up, Client will be billed directly for the full fee ($180) for that appointment. If Client am more than 15 minutes late for my designated appointment time, and do not call, it will be considered a No Call/No Show and Client will be charged the full fee ($180). Late cancellation is any cancellation notice given within 48 hours of the designated appointment time. Client will be billed directly for late cancellations at the rate of $180 per occurrence. If Client accumulates 3 late cancellations or No Call/No Show's in any combination client will be referred out to another counseling service. Most insurance providers will not cover distance counseling. Some insurance carriers will cover distance counseling via video conferencing, within their given parameters.

Client(s) are responsible to pay any copayment and/or deductible at the time of Client counseling session.

Client is responsible for the cost of any technology at Client location, such as a computer, device, phone, phone call charges, software, data charges and headset.

If client are in need of additional support between sessions and choose to use telephone calls, email or chat, client will be billed $3.60 per minute for every minute that exceed 10 in duration. Cash, personal checks, and all major credit cards are acceptable for payment. Client may pay via your client portal on https://nicolecburgess.secure-client-area.com/portal/, which uses Stripe (or Square if in person). Receipts for all of client payments will be available via your client portal under your billing tab. The receipt of payment may also be used as a statement for insurance if applicable to client. If client pay by credit card you might receive a receipt via email, and it will likely show up on your billing statement.

Therapist has a 24 Hour Sobriety policy. This means that should Client choose arrive in session under the influence of any substances not currently prescribed by their physician and taken in the proper, prescribed amounts, the session will not take place, but will be billed for. Therapy cannot proceed or be properly of value if Client chooses to not be sober and fully available.

Client understands that if the payment becomes delinquent, the Therapist will send the issue on to a collection agency with the intent that the agency will do what's necessary to collect the money. A $30.00 fee (or how ever much the bank charges the Therapist) will be charged for returned checks. Upon the occurrence of a returned check Client will be required to pay by cash or credit card for future sessions.

The Therapist does her best to avoid engaging in any client legal matters such as custody disputes or divorce proceedings. However, if legally compelled to do so, court time or consultations with third parties (NOT related to billing or treatment coordination) will be billed directly to the Client at the rate of $250.00 per hour a retainer fee of $500.

Time spent preparing letters, misc. paperwork, court documents etc. on behalf of a client will be billed directly to the Client at the rate of $50.00 per hour with a $25.00 minimum. Any copying of Client file will be billed at $10 for the first 10 pages, then $.25 per page thereafter.

The Therapist revisits her fee structure biannually and increases in our agreed upon rate may occur to reflect cost of living increases, trainings, and experience. Client will receive a minimum of 4 weeks notice should our fee agreement change and Client will have the option of continuing at the new rate or receiving a referral if preferred.


A credit card will be stored in the portal for any late cancel or no shows or on-line sessions.


HEALTH INSURANCE
Please inform the Therapist if you wish to utilize health insurance to pay for services. If the Therapist is a contracted provider for Client's insurance company, the Therapist will discuss the procedures for billing Client's insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of Client's specific insurance plan. Client should be aware that insurance plans generally limit coverage to certain diagnosable mental conditions. Client should be aware that Client is responsible for verifying and understanding the limits of Client's insurance coverage. Although the Therapist is happy to assist client efforts to seek insurance reimbursement, she is unable to guarantee whether Client's insurance will provide payment for the services provided to Client. Client is ultimately responsible for any claims not paid by your insurance company for any reason. Please discuss any questions or concerns that client may have about this with the Therapist. If Client have insurance that Therapist do not on panel with Therapist can provide client with an invoice and receipt to provide to Client insurance company.

Again, the cancellation of a counseling appointment requires 48-hours notice to offer time to refill the time slot. Failure to give adequate notice will result in your being billed for your reserved appointment time.
Please understand that if Client or the Therapist file insurance, appointments in which Client are not present, but still charged for (i.e. failure to arrive for your appointment or failure to give adequate notice of cancellation) cannot be filed for insurance reimbursement. Therefore, Client will be responsible for full fee payment.

CONFIDENTIALITY

All information disclosed within the Client's therapy sessions, including case notes and records, will be treated as confidential and, under some circumstances, as privileged. No information will be revealed to anyone not present in therapy without the permission of the client or a legally authorize representative unless there is an applicable legal or ethical exception. However, the Therapist is required by law to report any suspected child, elder or dependent adult abuse and any situation where the client threatens violence to an identifiable victim. The law also permits the Therapist to break confidentiality when the client presents a danger of violence to others or is likely to harm him or herself unless protective measures are taken. In addition, disclosures may be required in certain legal proceedings and actions.

If you participate in marital or family therapy, Therapist will not disclose confidential information about Client treatment unless all person(s) who participated in the treatment with Client provide their written authorization to release such information. However, it is important that Client know that your therapist utilizes a "no-secrets" policy when conducting family or marital/couples therapy. This means that if Client participates in family, and/or marital/couples therapy, Therapist is permitted to use information obtained in an individual session that Client may have had with her, when working with other members of Client's family. Please feel free to ask Therapist about her "no secrets" policy and how it may apply to you.

Client acknowledges that, in the event the Therapist becomes incapacitated or dies, it will become necessary for another licensed professional to take possession of my file and records. By signing this consent form, Client consents to allowing another licensee selected by the Therapist to take possession of your file and records and provide Client with copies upon request, or to deliver them to a new Therapist of Client's choice.

All questions regarding confidentiality, the release of information and waiver of privilege, etc., need to be brought up with the Therapist.

MINORS AND CONFIDENTIALITY

Communication between therapists and clients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child's treatment are often involved in their treatment. Consequently, your therapist, in the exercise of her professional judgment, may discuss the treatment progress of a minor client with the parent or caretaker. Clients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with therapist.

CONFIDENTIALITY OF RECORDS

All of Client PHI, protected health information, is kept for a minimum of seven years. It is my personal, professional, and legal obligation to keep all of your protected health information (PHI) confidential, with some exceptions. The Notice of Privacy Practices form on Counsol.com (which Client are asked to sign) provides detailed information about how private information about Client health care is protected, and under what circumstances it may be shared. Other than the exceptions listed on the Notice of Privacy Practices form, I, Burgess Counseling and Consulting LLC (Nicole Burgess) will be the only person viewing your information.

The following information explains how I handle and store Client PHI while Client are receiving counseling if Client chose any of the following counseling modalities. Although it is not guaranteed that these methods will prevent 100% of confidentiality breaches, they are designed with the intention of supporting the confidentiality of all clinical communications:

Face-to-face:

Face-to-face sessions in my office are provided behind a closed door. Client information is stored via Counsol.com which is HIPAA compliant and provides a BAA. Counsol.com uses point-to-point, federal approved, encryption.

The only information of Client that is stored on any electronic device of mine is Client phone number (on my phone), and Client email address (on my computer), if you have emailed me. My phone and computer are both password protected.

Any paper with Client personal information is kept in a locked cabinet behind a locked door.
Email:
All email correspondences will be done through https://nicolecburgess.secure-client-area.com/portal , unless Client request otherwise.
Counsol.com stores our email correspondence, but is it encrypted.
Chat:
All chat correspondences will be done through vsee.com/client portal, unless Client request otherwise.
Vsee.com/client portal) stores our chat correspondence, but is it encrypted.

Video Conferencing:
All video conferencing correspondences will be done through Vsee/Vsee.com, which is encrypted to the federal standard.

If Client use any other methods of electronic communication with me, Burgess Counseling and Consulting LLC (Nicole Burgess LMFT), there is a reasonable chance that a third party may be able to intercept that communication. However, Client have the right to consent to communication by non-secure means.
By signing this document Client, understand:

-that on Client https://nicolecburgess.secure-client-area.com/portal/ you have the option to choose to have email and text reminders of Client appointments and billing information, and that this form of communication not considered secure, and there is a risk of other people accessing this information.

-that on Client Counsol.com/client portal you have the option to sign a form titled "Communication Consent Form". This consent would allow me, Burgess Counseling and Consulting LLC (Nicole Burgess LMFT), to transmit to you protected health information via the unsecure methods that you specify.
-that Client are not required, nor encouraged, to sign the "Communication Consent Form" agreement in order to receive treatment.
-that Client may terminate these consents at any time by contacting me, Burgess Counseling and Consulting LLC (Nicole Burgess LMFT), or changing your preferences on Client Counsol.com/ client portal.

CLIENT'S RESPONSIBILITIES/CLIENT'S PROTECTION

With the use of technology it is important to be aware that family, friends, co-workers, employers, and hackers may have access to any technology, devices, or applications that Client use. I encourage Client to only communicate through a computer that Client know is safe, and to follow the safety measures that are detailed on the "Privacy Measures" document provided on https://nicolecburgess.secure-client-area.com/portal/. Client are responsible for reviewing the privacy settings and agreement forms of any applications or technology you use. Please contact me with any questions that Client may have on privacy measures.

CONTACTING THE THERAPIST
Telephone consultations between office visits are welcome. However, the Therapist will attempt to keep those contacts brief (no more than 10 minutes) due to her belief that important issues are better addressed within regularly scheduled sessions. Office hours are Tuesday 1:00 pm to 7:00 pm, Wednesday 1:00pm to 6:00pm, and Thursday 1:00 to 7:00pm. Phone and video sessions are available Tuesday through Thursday 10:00 am to 12:00 pm and afternoon hours are same as in office hours. Client may leave a message for the Therapist at any time on her confidential voicemail (317) 840-0490. If you wish the Therapist to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during normal workdays (Tuesday through Thursday). Client should be aware that this Therapist is generally available to return phone calls within 24 business hours and is not able to return phone calls or emails after 7 pm. Or by email using your client portal on counsol.com client portal. Additionally, Therapist may experience normal illness and will take vacations from time to time with reasonable notice to Client.

Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I am not prepared to watch them closely for important messages from clients. Please refrain from creating reviews of my services online. Online reviews are for the public to see and therefore they would put your confidentiality at risk. Any text based communication may become part of your record.
Burgess Counseling and Consulting, LLC is unable to provide 24-hour crisis service. I recommend that if you are feeling unsafe or need immediate medical or psychiatric evaluation you call 911, 800-662-3445, or go to your nearest emergency room.

Structure of Sessions

STRUCTURE OF SESSIONS

Therapist offers counseling via face-to-face, video conferencing, phone, chat, and email. Distance counseling is considered any of those methods other than face-to-face. If your counseling need is appropriate for distance counseling, client can either solely receive counseling via one medium, or any combination of them.

Face-to-face sessions are held at the following location: 7002 Graham Road, Suite 211, Indianapolis, IN 46220

Video conferencing counseling sessions are held via VSee @ Vsee.com.. It is recommended that client sign on to your VSee @ Vsee.com. account at least 5 minutes prior to you session start time. Client is responsible for initiating the connection with me at the time of your session.

Chat sessions are provided via VSee @ Vsee.com. Client is responsible for initiating the session. If sessions are requested via phone or chat client will have to have a brief interaction either face-to-face, or via video conferencing in order to verify your identity by matching you with your picture ID. During this initial verification client will choose a passphrase or number which you will used for all future sessions. This process protects client from another person posing as you.

Whenever there is communication that lacks visual or audio cues there is a risk of misunderstanding. When this happens it is important to assume that your counselor has positive regard for you, and to check out your assumptions. This will reduce any unnecessary hardship. If at any time you do not have internet access at your home, or private location you can contact me via phone to help you locate internet service that will be appropriate for distance counseling.

LIMITATIONS OF DISTANCE COUNSELING

Distance counseling should not be viewed as a substitute for face-to-face counseling or medication by a physician. It is an alternative form of counseling with certain limitations.

By signing this document client agree that you understand that distance counseling:
-may lack of visual and/or audio cues, which may cause misunderstanding.
-may have disruptions in the service and quality of the technology used.
-may not be appropriate if you are having a crisis, acute psychosis, or suicidal or homicidal thoughts.

EMERGENCY MANAGEMENT FOR DISTANCE COUNSELING

So that I am able to get you help in the case of an emergency and for client safety, the following are important and necessary. In addition, by signing this agreement form client is acknowledging that you understand and agree to the following:

Client, will inform me, your therapist, of the location in which you will consistently be during our sessions, and will inform me if this location changes.

Client, will identify, on your client information form, a person, whom I, your therapist, am allowed to contact in the case that I believe you are at risk. Client or Therapist, will verify that this emergency contact person is able and willing to go to your location in the event of an emergency, and if I deem necessary, call 911 and/or transport you to a hospital.

BACKUP PLAN IN CASE OF TECHNOLOGY FAILURE

The most reliable backup is a phone. Therefore, it is recommended that client always have a phone available and that Therapist, know your phone number. If client get disconnected from a video conferencing or chat session, end and restart the session. If client is unable to reconnect within ten minutes call me. If client is on a phone session and your phone disconnects call me back, or contact me to schedule another session. If this happens as a result of my phone or phone service, and we are not able to reconnect, you will not be charged for the session.

TERMINATION OF THERAPY

The Client's therapeutic and financial relationship with the Therapist continues as long as the Therapist is providing professional services until the client informs her, in person or in writing, that the Client wishes to terminate therapy, or the therapist notifies the client that therapy is being terminated. Burgess Counseling and Consulting, LLC reserves the right to terminate therapy at the therapists' discretion, for reasons including, but not limited to untimely fee payment, noncompliance with treatment recommendations, conflict of interest, failure to participate in therapy, or clients needs are outside the therapist's scope of practice or competence. Client has the right to terminate therapy at client's discretion with the appropriate notice to cancel all further sessions in order not to accumulate fees for late cancels or no call/no shows.

I, Client, agree to meet with the Therapist at least once before stopping therapy. Client agrees to pay for all services provided up until the time the therapy relationship is terminated.

CHANGES TO THIS POLICY

Burgess Counseling and Consulting, LLC has the right to change this Agreement at any time. Any change could apply to personal information the Therapist already have about Client as well as any information therapist receives in the future. Therapist will maintain a copy of the most current notice on the website and in the office.

SIGNATURE OF AGREEMENT

By signing below, Client acknowledges that you have reviewed and fully understand the terms and conditions of this Agreement and is doing so voluntarily and not because of any distress, threat, menace or undue influence made by Therapist or anyone else. Client has had ample opportunity to read, discuss and consider this Agreement. Client fully understands the meaning and effect of this Release including the fact that by signing this document, Client is giving up any and all legal claims Client may have against Therapist. With said meaning and effects in mind, Client knowingly and voluntarily intends to be bound by all the terms of this Document.

( Type Full Name )
Social Media Policy

Social Media, Texting & Email Policy

Social Media is a fantastic tool that helps people get informed and engaged. I use social media for my practice and in an effort to be completely transparent with you, I have created a social media policy so you understand how I use social media in my practice.

If you have any questions about my policy, I encourage you to bring them up when we meet It is also something that is constantly changing and there may be times when I need to update this policy. If I do so, I will post the policy online and inform you of the changes in our session. 

The basis for this policy is to truly protect our relationship and your confidentiality in session. Let's talk about confidentiality for a moment. You are the person that can decide what you want to keep confidential. I must keep my relationship with you completely confidential except in cases of where you might harm yourself or others (see informed consent for details). Thus, if you post on my page, you are opening up the

possibility of people inferring about our relationship or asking you about your connection to me. You get to decide what you tell people. You have a choice as to what you reveal about yourself online, however, I will not reveal my connection to you. Thus this is how I handle different social media options:

FRIENDING To respect your privacy and confidentiality, I do not accept friend requests on my personal Facebook page from current or former clients on any social networking site.

FANNING You may "like" my Facebook business page. However, the information on my facebook page is often on my website as well. If you "like" my page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. However, if you find it helpful then that is great!

FOLLOWING I sometimes publish a blog on my website and I post psychology news on Twitter and Facebook. I have no expectation that clients will want to follow my blog or Twitter stream or Facebook. You are welcome to use your own discretion in choosing whether to follow me. Note that I will not follow you back. I mainly follow other health professionals on Twitter and I do not follow current or former clients on blogs or Twitter. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together, during the therapy hour.

INTERACTING Please do not use messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. Also if there were an emergency, I would not be able to respond timely as I do not check these accounts regularly. The best way to interact with me is by email or phone. If you post on my wall it may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.

USE OF SEARCH ENGINES You may have a Facebook page, Instagram account or Twitter account. I do not "google" my clients or look up information on them for any reason. I think it is important that I know you as you are in my office. If I do come across your information online, I will move on and avoid reading content.

BUSINESS REVIEW SITES I do have other directory pages. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client. The American Association of Marriage and Family Therapist's Ethics Code states that it is unethical for MFTs to solicit testimonials. Of course, you have a right to express yourself on any site you wish. If you do post a review, I cannot respond on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my Ethics Code prohibits me from requesting testimonials. But you are more than welcome to tell anyone you wish that I'm your therapist or how you feel about the treatment I provided to you, in any forum of your choosing.

If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection.

EMAIL I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider.

TEXT Sometimes clients text me to request an appointment time or to let me know if they are running late to an appointment. Just know, text isn't always secure. I am fine with brief texts related to your appointment only.

CONCLUSION Thank you for taking the time to review my Social Media, Texting & Email Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them.

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