Appointment Bookings

CONSENT FOR TELEHEALTH:

SHREDERS AND ASSOCIATES, PLLC

CONSENT FOR TELEHEALTH CONSULTATION:

1. I understand that my health care provider wishes me to engage in a telehealth consultation.
2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY SIMPLE PRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:
• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

BY AGREEING TO THIS CONSENT POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

NOTICE OF PRIVACY PRACTICES: SHREDERS AND ASSOCIATES, PLLC

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 personal 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:
1. 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.

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

3. 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:
1. 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.

2. 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.

3. For health oversight activities, including audits and investigations.

4. 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.

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

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

7. 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.

8. 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.

9. 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.
10 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.
1. 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:
1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

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 HIPAA Notice of Privacy Practices.

BY AGREEING TO THIS POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

INFORMED CONSENT FOR PSYCHOTHERAPY: SHREDERS AND ASSOCIATES, PLLC

Informed Consent for Psychotherapy: General Information:

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process:

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality:

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

BY AGREEING TO THIS CONSENT POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

PRACTICE POLICIES: SHREDERS AND ASSOCIATES, PLLC

APPOINTMENTS AND CANCELLATIONS:
New clients must complete all intake documentation 3 days prior to their initial session. This includes completing all intake forms, uploading up to date health insurance information, and putting an up-to-date payment method on file.
Failure to complete intake documentation fully 3 days prior to the initial session will result in the appointment being cancelled until documentation is completed in its entirety.
For clients with recurring appointments, failure to attend two consecutive sessions will result in removal from the recurring appointment schedule. This policy ensures that time slots can be made available to other clients in need of consistent appointments.
It is the client’s responsibility to keep an updated credit or debit card on file. Failure to keep an updated payment method on file will result in cancellation of further sessions until payment is made in full. Failure to do so could result in outstanding balances being sent to collections.
Client is responsible for a $75 fee if cancellation is less than 48 hours prior to the session.
The standard meeting time for psychotherapy is 53-60 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 53 minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
Cancellations and re-scheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.
ADDITIONAL FEEES:
A $100 fee will be charged for paperwork completed by clinicians. This includes but is not limited to FMLA documents, treatment letters for employment purposes, court documents, legal documents, and VA paperwork.
INSURANCE COVERAGE:
Our office DOES NOT accept Medicaid or Medicare at this time.
( It is the client’s responsibility to disclose this otherwise the current billable rate will apply).
If the client has not met the insurance deductible at the time of sessions, our practice will submit the claims to the insurance provider on the client’s behalf. The client will then be responsible for paying for any outstanding deductible.
It is the client’s responsibility to notify the practice of changes in health insurance coverage/benefit changes. If client’s do not notify the practice prior to sessions, ongoing sessions without insurance coverage will be charged the standard $150 per hour self pay policy.
All insurance claims will be submitted on the client's behalf. Should the insurance provider not cover the cost, each session will be subject to the $150 rate for a 1 hour session.
TELEPHONE ACCESSIBILITY :
If you need to contact the office between sessions, please leave a message on the office voice mail. If not immediately available, we will attempt to return your call within 24 hours. For emergency situations, please call 911 or visit your local emergency room.
ELECTRONIC COMMUNICATION:
We cannot ensure the confidentiality of any form of communication through electronic media, including text messages and email. Please do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist choose to use information technology for some or all of your treatment, : (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. 3.) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.
TREATMENT OF MINORS:
If you are a minor, your parents may be legally entitled to some information about your therapy. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION :
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion with you and a termination process if we determine that the psychotherapy is not being effectively used or if you are in default of payment. We 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, we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

BY AGREEING TO THIS CONSENT POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

CLIENT FINANCIAL RESPONSIBILITY FORM: SHREDERS AND ASSOCIATES, PLLC

Thank you for choosing Shreders and Associates, PLLC for care. We ask that you read and agree to this form to acknowledge and agree to accept financial responsibility for services rendered by the Provider to the Client.

I agree that I am legally responsible and agree to pay the Provider for all fees, charges and expenses incurred by the below Client or owed to Shreders and Associates, PLLC in connection to the Provider providing care to the Client.

I acknowledge and agree that I am ultimately responsible for the payment to the Provider for any and all services rendered by the Provider to the Client.

BY AGREEING TO THIS CONSENT POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

PARENTAL CONSENT FOR TREATMENT OF MINORS:

SHREDERS AND ASSOCIATES, PLLC

The best treatment for children is within the context of their families. Children with divorced parents have ongoing developmental needs for regular contact with both parents, unless it can be shown that this contact threatens the child’s safety or mental health.

Parents are entitled to understand the nature of their child’s problem as well as the method and course of treatment. However, children will experience the best outcomes if they can trust the therapist with their innermost thoughts, feelings, and opinions.

The involvement of court hearings and proceedings is counterproductive to the goals of the counseling relationship. The therapist is not a custody evaluator, and therefore, cannot provide any recommendations or commentary on anything related to the child’s physical or legal custodial situation.

LEGAL / CUSTODY:

The therapist will require a copy of court documentation indicating custody arrangements, allowances or restrictions for contact between parent and minor child, court orders for counseling or any other legal documentation related to the medical care of the child before any counseling will take place.

The therapist will attempt to involve both parents in the counseling process unless doing so would be detrimental to the child’s mental health or interfere with the child’s treatment.

CONFIDENTIALITY:

All verbal and written communication (telephone, face-to-face, email, or written) from either parent is considered part of the clinical record, and can be shared with the other parent and with the child at the therapist’s discretion.

The law entitles parents with legal custody to information regarding their child’s treatment and generally entitles parents to copies of their child’s health records. However, it provides an exception for the release of health records in the case of mental health.

Mental health records are kept confidential to protect the child’s ability to speak freely about their relationships and concerns regarding each parent. It is rarely in the child’s best interest to have therapy records read by parents.

Parents are encouraged to meet regularly with their child’s therapist to obtain information about their child’s health and treatment.

It is the policy of Shreders and Associates, PLLC that, in order to preserve the therapeutic relationship with the child, the therapist will not testify in court. If this policy is disregarded and the therapist is subpoenaed and required to go to court, the fee will be $500/hr for any and all court-related time.

Parents are not permitted to record sessions, phone conversations, or any other communications without express, advance, written permission from all parties (therapist, both parents, and child).

COMMUNICATION:

The therapist welcomes involvement of step-parents, siblings, grandparents, and others, but participation in therapy and access to the therapist is determined based on the child’s needs, the parents’ wishes, and the family’s circumstances. Communication with extended family and/or stepfamily will not be allowed unless both parents consent to that communication.

The therapist will offer parent progress review sessions regularly to both parents who have legal custody.

The therapist will not accept phone calls, voicemails, emails or other communications directed at pitting the therapist against the other parent. The therapist reserves the right to refuse to accept information deemed inappropriate for the counseling relationship.

FINANCIAL:

The parent or guardian who registers the child for services as a client at Shreders and Associates, PLLC is established as the guarantor and is responsible for payment of the account at the time of service.

When parents who are divorced have agreed to share health care expenses, it is the responsibility of the guarantor of the account to pay the fee and to collect reimbursement from the other parent if sharing expenses.

If there is a communication problem resulting in a missed appointment, the guarantor is responsible for payment of the missed appointment fee.

Parents are expected to inform each other about scheduled appointments. The no-show fee will apply if an appointment is missed regardless of which parent scheduled the appointment.

BY AGREEING TO THIS CONSENT POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

SHREDERS AND ASSOCIATES, PLLC

I understand as the client, it is my responsibility to notify the provider of any changes in health insurance plan/coverage prior to scheduling follow up sessions.

BY AGREEING TO THIS CONSENT POLICY I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

CREDIT CARD AUTHORIZATION: SHREDERS AND ASSOCIATES, PLLC

By your electronic signature of this form, you authorize charges to your credit card through Stripe via Simple Practice for services rendered. These charges will appear on your bank/credit card statement as SHREDERS AND ASSOCIATES, PLLC. You have the right to request a paper copy of this document.

I authorize SHREDERS AND ASSOCIATES, PLLC to charge my credit card through Stripe. I also agree that my credit card can be charged for any session that is not cancelled at least 48 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify SHREDERS AND ASSOCIATES, PLLC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.