Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and ask me any questions you may have. When you electronically sign this document, it represents an agreement between us.

Psychological Services

Participation in therapy can lead to a number of benefits, including improvements in relationships, resolution of specific problems, positive behavioral changes, and personal growth. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable emotions. Change can often happen quickly, although it may occur more slowly. There are no guarantees about what you will experience in therapy.

As many as the first few sessions will involve an evaluation of your needs. By the end of the evaluation I will be able to offer you some first impressions of what our work will include and a general treatment plan.

After the evaluation, we can both decide if I am the best person to provide services you need in order to meet your treatment goals. If not, I will refer you to another therapist. We will work together to establish specific, individualized goals for treatment. Throughout therapy, we will continue to assess whether your goals are being met and/or whether they require revision. There are many different methods I may use to deal with the problems that you hope to address. If you have questions about my process or methods, we should discuss them whenever they arise.

Client's Role

In order for therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. You are expected to play an active role in your treatment, including collaborating with me to identify treatment goals, completing questionnaires when appropriate, and designing and completing homework assignments throughout our work together.

Confidentiality

Your discussions with a licensed psychologist are considered confidential, which means these discussions are protected by law. I may not disclose information about you without your formal written consent. There are situations, however, in which I am required by law to break confidentiality. These situations include:

1) If I suspect you are in danger of harming yourself or another person or are unable to care for yourself.
2) If there is suspected child abuse or neglect, or suspected elder or dependent adult abuse.
3) If you knowingly access, stream, or download electronic or digital material where a child is engaged in an obscene sexual act.
4) If I am court ordered to release information as part of a legal proceeding, or otherwise as required by law.

Professional Fees

The fee for a 50 minute session is $245.00 (Please note: for Lyra clients this is covered by your benefit). Fees for longer or shorter sessions will be prorated from this fee. There will be no charge for brief telephone calls. However, you will be charged the typical session fee (prorated according to length) for calls longer than 10 minutes. There is typically a small increase in fees each year and this generally occurs around January 1.

Billing and Payments

Payments are to be made at the beginning of each session. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due. In the event suit is brought or an attorney is retained by either party to this Agreement to enforce or interpret any of its terms or to collect any sums owed hereunder, the prevailing party shall be entitled to recover all costs incurred, including reasonable attorneys' fees, in addition to any other relief to which the party may be entitled.

If you wish to receive insurance reimbursement for your sessions, it will be your responsibility to complete the insurance forms and obtain reimbursement. At your request I will provide a monthly receipt of services and diagnosis codes that your insurance company may require.

Social Media and Telecommunication

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Cancellations, Missed Sessions, and Tardiness



Contacting Me

If you are experiencing a medical or psychiatric emergency, immediately call 911 or go to your nearest emergency room.

For all non-urgent matters, you may contact me through the teletherapy platform (i.e., Counsol.com). I will make every effort to respond to your message the same day you send it or by the next business day. If you request that I contact you by phone, please inform me of some times when you will be available. If I am unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

Ending Therapy

You may end therapy at any time. A final session is strongly recommended for closure of our work together.

I may terminate treatment after appropriate discussion with you and a termination process if I determine that the therapy is not being effectively used, is inappropriate for your needs, or you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment with me for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

I have read and understood the above and give my consent to participate in psychotherapy treatment.

Effective Date: 10/11/2016

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

If you have questions about this notice, please contact your therapist. Thrive TeleTherapy is committed to protecting your personal health information and we want to assure you that we understand the sensitive and personal nature of the information provided to us during the course of your treatment. We also want to make you aware of how your protected health information is used and stored.

In order to provide you with quality care and to comply with legal requirements, we create a record of the services you receive with us.

We are required by law to:
• Make sure that information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

The following categories describe different ways that we use and disclose your health information. We will provide you with examples of each category to help explain the purpose for the disclosure, but not every use or disclosure within that category will be listed. However, all of the ways we are permitted to use and disclose your information will fall within one of these categories.

Treatment
We may use information about you to provide you with treatment or services. Your therapist may also need to disclose information about you to a psychiatric hospital should you require inpatient treatment, or in a psychiatric emergency as deemed necessary to protect the health and safety of you or others.

Payment
Thrive TeleTherapy does not accept third party reimbursement. Therefore, information about you will not be disclosed for payment purposes. If you would like to submit a claim to your insurance provider, you may request that your therapist provide you directly with a monthly statement.

Health Care Operations
We may use and disclose personal information about you for Thrive TeleTherapy’s operations. These uses and disclosures are necessary to make sure all of our consumers receive quality care. We may use information about you contained in your health record to review our treatment and services, and to evaluate performances of staff in caring for you. We may also disclose information to those designated to review our procedures and practices to ensure we are in compliance with regulations and that the services we provide to you meet acceptable standards of care.

Coroners or Medical Examiners
We may release information to a coroner or medical examiner as authorized by law. This may be necessary, for example, to identify a deceased person or determine the cause of death.

National Security and Intelligence Activities
We may release health information about you to authorized federal officials for national security activities as authorized by law.

Protected Services for the President or Others
We may disclose health information about you to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations as authorized by law.

Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights regarding the health information we maintain about you:

Right to Inspect and Copy
You have a right to inspect and copy your health information that may be used to make decisions about your care. There may be some exceptions to this right, such as when information requested contains specific identifying information about another person, or for mental health clients, when a licensed health care professional believes that the access of that information may endanger the life or physical safety of you or another person.

You further have a right to have any denials of access to your information reviewed by another licensed health care professional designated by Thrive TeleTherapy to review consumer complaints and who did not participate in the original decision to deny. We will comply with the outcome of this review.

To inspect and copy your health information, you must submit your request in writing to Thrive TeleTherapy. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, compiling a summary, or other supplies associated with your request. The total cost will depend upon the number of pages you want to have copied and mailed. The information regarding the cost to you can be provided prior to copies being made.

Right to Amend
If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have a right to request the amendment for as long as the information is kept by or for us.

To request an amendment, your request must be made in writing and submitted to Thrive TeleTherapy. In addition, you must provide a reason that supports your request.

We may deny your request if it is not made in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend the information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the information kept by or for us;
• Is not part of the information which you would be permitted to inspect or copy, or;
• Is accurate and complete.

Right to an Accounting of Disclosures:
You have the right to an “accounting of disclosures.” This is a list of disclosures we made of health information about you, other than for releases for which you provided written authorization, or for releases used for purposes of treatment, payment, and health care operations, as those functions are described above.

To request a list or accounting of disclosures, you must submit your request in writing to Thrive TeleTherapy. Your request must state the time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request in a 12-month period will be free. There may be a fee for any additional lists requested within a year. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

I have received a copy of Thrive TeleTherapy’s Notice of Privacy Practices for Protected Health Information and have been given the opportunity to review the Notice prior to signing the form. Thrive TeleTherapy reserves for itself the right to change the terms of its Notice of Privacy Practices for Protected Health Information at any time. If the terms of the Notice of Privacy Practices do change, I may obtain a copy the revised Notice by contacting Thrive TeleTherapy at any time after the change or at the time of my next visit.

I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND I AM THE CONSUMER OR I AM AUTHORIZED TO ACT ON BEHALF OF THE CONSUMER TO SIGN THIS DOCUMENT. BY SIGNING THIS FORM, I AM AGREEING TO THE USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR THE PURPOSES DESCRIBED.

Teletherapy refers to the provision of psychotherapy via online video-conferencing. It requires the use of two remote computer users with cameras and an internet connection, and otherwise is much the same as a face-to-face psychotherapy session. You sit and talk with your therapist just as you would if you were in a clinic with your therapist.

This service is confidential and every effort has been made to ensure a secure connection. Thrive TeleTherapy utilizes a state-of-the-art service to protect the privacy of all counselors and clients. Servers are housed in Tier-IV data center with SSAE16, HITRUST, ISO 27001 & PCI 2.0 compliance, all traffic is required to use SSL (Secure Socket Layer) with 256-bit encryption, including 256-bit encryption of all sensitive data. No sensitive information is sent via email, only notifications to login will be sent. All the required components are in place to make this service more than HIPAA compliant.

Risks and Benefits

In accordance with California law regulating the ethical use of telemedicine technology, it is important that you understand the risks and benefits associated with teletherapy. Reasonable and appropriate efforts have been made to reduce the risks associated with teletherapy, and all existing confidentiality protections under Federal and California laws apply to information disclosed during teletherapy. Despite these measures and protections, there remains a risk that: the transmission of information could be disrupted or distorted by technical failures in transmission; the transmission of information could be intercepted by unauthorized persons; and/or the electronic storage or medical information generated by teletherapy in one or more databases could be accessed by unauthorized persons. Also, the physical distance from provider to patient may make any crisis interventions more challenging.

Potential benefits (beyond face-to-face psychotherapy) include: more convenient access to your therapist and less time spent commuting to/from the therapist's office.

Rights and Responsibilities

Using teletherapy in no way diminishes your rights as a patient and you continue to have the right to withhold or withdraw your consent to teletherapy at any time without affecting your right to future care or treatment and without risking the loss of your health coverage. You have the option of using face-to-face therapy with a therapist who is not included in Thrive TeleTherapy.

The laws which protect the confidentiality of psychotherapy information apply to teletherapy. No information or images from teletherapy which identify you will be disclosed to researchers or other entities without your consent. Furthermore, you agree to not record the teletherapy session without the consent of the therapist. You also understand that you must meet the technical requirements necessary to conduct teletherapy (cable or DSL with minimum download speed of 3Mbps and minimum upload speed of 384Kbps). You also understand that telephone sessions will be conducted as an alternative to video-conferencing if technical issues hinder teletherapy via the video-conferencing platform. As a result, we require that you have a cell phone or landline available for your therapist to call in case we encounter technical difficulties.

I have read and understood the above and give my consent to participate in psychotherapy treatment using teletherapy equipment.