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 $210 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 ($210) 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 ($210). 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 $210
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
$3.70 per minute for every minute that exceed 10 in duration.
Currently, all major credit cards are acceptable for payment. Cash
and personal check can be used if in-person sessions. 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 $300.00 per
hour a retainer fee of $1500.
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
This Therapist is not paneled on any insurance plans. Please
inform the Therapist if you wish to utilize health insurance to
pay for services, so Therapist can discuss how you can print the
Invoice for the 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.
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: (As of March 31, 2020 and going forward this option
is unavailable)
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 for phone and video sessions are Tuesday 10:00 am to 6:00
pm, Wednesday 10:00am to 6:00pm, and Thursday 10:00am to
7:00pm. 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 6 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 video conferencing, chat, and
phone. 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.
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 your session start
time. Therapist will initiate the connection at the time
of your session. Client must be logged on to the
platform in order for session to be initiated. Chat sessions are
provided via VSee @ Vsee.com.
If sessions are requested via phone client will have to have a
brief interaction 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. Client is
responsible in initiating a phone session with therapist at
the time of your session.
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.