Consent for Services

Welcome to Perennial Counseling & Consulting! We look forward to working with you. This form is called a Consent for Services (the "Consent"). Your therapist ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

The Therapy Process
Participation in psychotherapy may result in a number of benefits to you, including resolution of the specific concerns that led you to seek treatment and improvement in overall functioning and quality of life. Changes are sometimes easy and swift, but more often they are slow, requiring your active effort and involvement. Given that therapy is a collaborative endeavor, you are encouraged to ask any questions or bring up any issues you may have throughout the duration of our work. Participation in therapy is voluntary - you can stop at any time. Over the course of your initial evaluation and therapy sessions, remembering and discussing painful experiences may result in discomfort or strong emotional responses. Additionally, psychotherapy may lead to decisions about changes in behavior, career, relationships, or other significant life choices. There is no guarantee that psychotherapy will yield positive or intended results.

Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through telehealth. At some point, you will achieve your goals or otherwise determine you have completed therapy. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

Telehealth Services
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:

  • Risks:

    • Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.

    • Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.

    • Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.

  • Benefits:

    • Flexibility. You can attend therapy wherever is convenient for you.

    • Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.

  • Recommendations:

    • Make sure that other people cannot hear your conversation or see your screen during sessions.

    • Do not use video or audio to record your session unless you ask your Provider for their permission in advance.

    • Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

Confidentiality
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
- Your Provider may speak to other healthcare providers involved in your care.
- Your Provider may speak to emergency personnel.
- If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
- If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
- If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
- If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

Record Keeping
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

Communication
You decide how to communicate with your Provider outside of your sessions. You have several options:

  • Texting/Email: Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.

  • Secure Communication: Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.

  • Social Media/Review Websites
    - If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
    - Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
    - If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

Appointments and Cancellations
Sessions are between 45-53 minutes. Please make every effort to arrive on time so that you may receive all of your allotted time. If you are late, we will still end the session as scheduled. Because the scheduling of an appointment involves the reservation of a time specifically for you, a minimum of 24 hours notice is necessary for rescheduling or canceling an appointment. The full fee of the appointment will be charged for sessions missed without such notification.

Fees and Payments for Services
You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:

  • Balance Accrual
    - Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.

  • Administrative Fees
    - Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.

  • Insurance Benefits
    - Before starting therapy, you should confirm with your insurance company if:
    --Your benefits cover the type of therapy you will receive;
    --Your benefits cover in-person and telehealth sessions;
    --You may be responsible for any portion of the payment; and
    --Your Provider is in-network or out-of-network.

  • Sharing Information with Insurance Companies
    - If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.

  • Covered and Non-Covered Services
    - When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
    - When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.

  • Payment Methods
    - The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

Emergency Procedures
Your Provider will check their voicemail, text messages, and email frequently during regular business hours (M-F, 9-5pm). Every attempt will be made to return your message in a timely manner as circumstances permit. Outside of normal business hours, feel free to leave messages regarding scheduling or other non-emergency issues. In the event that you find it to be helpful, we can arrange to speak over the phone between sessions. There is no fee for phone calls less than 10 minutes; calls longer than 10 minutes are considered partial sessions and will be charged on a prorated basis. If an emergency does arise and you need urgent psychiatric or medical assistance, please contact 911 or present at your nearest emergency room.

Complaints
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.