Client Informed Consent

As a current or past client of E&E, this is where you will find the most up-to-date practice policies and information relating to informed consent as a client. Please if you have questions bring this up to your therapist in a session to clarify any concerns that you may have.

Empower and Elevate, LLC
10210 Grogans Mill Road, The Woodlands, TX 77380
832.409.4679
Effective Date: June 1st, 2024

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, we need to reach a clear understanding of 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 circumstances 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.

Practice Policies

Credit Card Authorization Form

A valid credit card is required to be on file before us confirming an appointment.

Please note that the information on this form will be securely entered and stored in a HIPAA compliant online virtual terminal that is password-protected for your safety. Once your information has been entered, by your therapist to the secured terminal, these paper forms will be shredded and destroyed immediately to protect your information. While all secure methods to protect your information are in place, and we take your safety seriously, no company can 100% guarantee that any online system cannot be breached, thus you are accepting responsibility and risk in allowing Empower and Elevate to store your information for therapy charges.

I authorize my therapist with Empower and Elevate to keep my signature and card information on a virtual terminal file that is password protected and HIPAA compliant in order to charge therapy session fees (individual, group, workshops, couples, family or other), and any fees related to therapy-related materials (workbooks, DVD’s, CD’s, and other materials, and/or fees), or for any appointments with my therapist that are not cancelled 48 hours before the scheduled appointment time to be charged to my credit, charge, or debit card as filled out below for therapy services provided to client. Client Credit Card Authorization Form I understand that this authorization is valid until canceled in writing. I understand that though this information is secured in an online protected client file, and is unlikely to be tampered with, I agree to assume the risk if the file and credit card information is compromised. I understand that charges for ongoing services or materials will normally be posted to my credit/debit/flex card account within 48 hours of each session date and my session fee will be charged at the start of the day on the day of my session. Additionally, I agree that the card listed below may be charged by my therapist with Empower and Elevate to settle any outstanding balances accrued by the above listed client upon termination of therapy services including any materials (i.e., books, CD’s, DVD’s) that I have not returned within one week of completion of my therapy services. I understand that if a charge back fee is incurred or a retrieval fee of is incurred, I am responsible for these fees. I agree that if I have any concerns or questions regarding charges to my account, or if the charge fails to post to my account, I will contact my therapist with Empower and Elevate for assistance and/or disclosure. I agree that I will not dispute any charges with my credit card company unless I have already attempted to rectify the situation directly with my therapist and those attempts have failed. Further, if I am assuming session payment responsibility for the client above whose name is listed in the printed area, and that client is someone other than myself, I understand that I am not entitled to information pertaining to confidential therapy sessions as provided by this person’s therapist at Empower and Elevate I understand and agree to these terms. I understand the conditions of this payment policy and agree to the conditions stated above.

Counselor/Therapist Time Off Policy

Our counselors/therapists take between 4-6 weeks off during a calendar year, depending on the counselor. This time off is used for speaking, writing, supervising, ongoing education, professional conferences, and for personal time. You will be notified in advance of any time taken when an appointment will be missed with you. Please note that if you are seen for therapy every other week, there will be some weeks where there is a an extra 2-week gap given your session is shared with another client and upon our week of return, the other client may be up first for the shared session time. During the counselor’s out of office time, they will not be available for individual, group, family, or couple’s counseling both in person, via email, text, telehealth, or phone. Instances of serious crisis, or life-threatening emergency where there is imminent danger to self or others, please call 911 immediately. On occasion you may be provided the phone number and contact information of a therapist colleague who may fill in during a counselor’s time away for emergency situations. We ask that clients respect a counselor’s time away and unless there is a critical emergency, they wait until the next session to discuss. We will respond the first business day upon returning to the office. Please respect this boundary regarding emailing, texting, and calling during our time away.

Good Faith Estimate

Effective January 1, 2022, under Section 2799B-6 of the Public Health Service Act, a ruling went into effect called the "No Surprises Act" which requires practitioners to provide a "Good Faith Estimate" about out-of-network care.

At E&E we never want the cost of therapy sessions to be a surprise. I will provide all expected fees up front so that you can make the best decisions based on your needs and circumstances. I will collaborate with you on length of treatment, overall care, and costs associated with those specific services.

What is a Good Faith Estimate?

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. You can ask any health provider you choose, for a Good Faith Estimate before you schedule a service.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance a Good Faith Estimate of the expected charges for medical services, including psychotherapy services. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate and the No Surprises Act, visit www.cms.gov/nosurprises or call (800) 985-3059.

Court Related Fees & Services

1. Court testimony costs begin at $500.00 an hour with a minimum charge of three hours. A retainer of $1500.00 is due before any court related services are provided.

2. Travel is billed a 0.75/mile. Failure to provide the specific fees as described constitutes are lease from the requested court appearance.

3. It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer is forfeited. If proper notice is given, the retainer will be refunded.

4. Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email or letter, documentation review and/or documentation preparation are also billed at $500.00 per hour, rounded to the nearest 15-minute increment.

5. In cases where a therapist is being contracted to work with a child in a divorce/custody case, a certified copy of the temporary orders or divorce decree must be provided prior to the therapist beginning treatment.

Court Reports or Letters

The therapists of Empower and Elevate do not write legal letters or court reports on behalf of clients involving divorce, custody, other legal matters, or lawsuits. We do not write letters pertaining to legal matters to any outside person (i.e., doctor, school, attorney, etc.) or agency regarding your treatment. If a special circumstance arrives where a letter is required by court order, it will require your written consent and will be billed to you at $25.00 per page and in addition to our hourly fee. We reserve the right to refuse to write letters on your behalf (unless court mandated) if we do not feel this would be in your best interest, if it places us in a dual relationship, or will compromise our therapeutic relationship. We will not write letters on your behalf if you are involved in a lawsuit for any aspect of your personal or professional life, as this places us in a dual relationship as both your therapist and court advocate, thus crossing therapeutic boundaries.

If you are involved in a lawsuit, please understand that entering your mental health into a court hearing may not always be in your best interest as it may compromise your confidentiality and your clinical files may be requested and your therapist must speak honestly if under oath.

Your therapist will not be your advocate in a court hearing or speak on your behalf as that is not the nature of the therapist/client relationship.

If you become involved in legal proceedings that require your therapist’s mandated participation, you will be expected to pay for all your therapist’s professional time, including preparation, transportation time, and costs (as outlined above), even if called to testify by another party.

Because of the time involved and the interruption to my clinical work, you will be charged $500 per hour for time out of practice, time for preparation, travel time, and attendance at any legal proceeding on your behalf that you will be responsible for.

Additionally, if other client sessions must be cancelled, these must be covered at the rate of those sessions and will be billed to you. Court fees can be very expensive, and your signature below indicates that you understand your financial responsibility in covering these expenses should your therapist be mandated to go to court for a legal issue you are involved in. A therapist is not a court advocate or friend. A therapist must legally speak truthfully under oath.

Pandemic Consent:

The Pandemic virus is a serious and highly contagious disease which has required state and local health officials to provide guidelines to manage the spread of the virus. The staff at Empower and Elevate (E&E) have used these guidelines as the minimum standard for in person counseling services. For your safety and the safety of our staff and community, you must comply with all measures and protocols to receive in person services at E&E. These protocols are subject to change based on the best information we have from those health officials.

All clients and guests must wear a mask when in the common spaces.

All clients must wear a mask in the therapist office if required by your individual therapist.

All clients must wash or disinfect their hands upon entering the building, after they use the restroom, and anytime they touch their face.

All clients must maintain 6 feet of distance from anyone in the building, unless they are from the same household.

All clients must wait to enter the office until the start time of their session. Please wait outside or in your car until your therapist notifies you that they are ready, and they will come retrieve you. Currently, our waiting room is closed.

All clients understand they will be asked Pandemic screening questions about any symptoms they have. E&E staff have the right to ask you to reschedule using telehealth if you say “Yes” to any questions.

All clients understand that they will have their temperature checked upon entering the office. Clients with a temperature above 100.4 will not be able to attend their therapy session in-person and will be asked to engage in telehealth for two weeks or until cleared by a doctor.

All clients will be required to sanitize their hands upon entering the office.

Clients who identify as a member of the vulnerable/high risk population must continue teletherapy until further notice. All clients who attend in person therapy sessions agree that they are not a member of the vulnerable or high-risk population.

Clients who test positive for the Pandemic Virus and have attended an in-person therapy session in the past 2 weeks must notify their therapist immediately. If you should test positive for the Pandemic Virus, in-person services will be paused and telehealth will resume, for the duration of two weeks or until you are cleared by a doctor.

In person visits may not be available for every therapist of E&E, due to their personal needs.

We reserve the right to require telehealth appointments of any or all clients versus in person appointments if we feel it is necessary to maintain the safety of E&E staff and our clients.

Due to the long incubation period of the Pandemic, as well as the reality that an individual may be a carrier of the virus without any symptoms or awareness, face to face contact with any other member of the community increases risk of transmission of the virus.

E&E will continue to provide individual, couples and family therapy via a telehealth platform. We strongly suggest that clients continue to use telehealth for therapy services and that in person sessions be used for clients with whom telehealth is not possible or suggested, such as clients with privacy or safety issues, clients who receive therapy by certain modalities that are not conducive to telehealth, and clients who need a higher level of care. By choosing in person sessions over telehealth, you recognize the increased risk of contracting the virus in the office and accept that risk.

Client Acknowledgement:

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the Pandemic virus in coming to this office and being in this office for in person sessions. I understand and accept the additional risk of contracting the Pandemic Virus from contact at this office. I also acknowledge that I could contract the Pandemic virus from a multitude of sources outside this office and unrelated to my visit here. I acknowledge it would be very difficult for anyone to prove from whom or where they contracted the Pandemic Virus. I assume the risk of being in this office and proceeding with services at E&E.

Emergency Contact Form

Please provide Empower and Elevate with an emergency contact. This person should be someone not listed on the information forms above.

I authorize any representative of Empower and Elevate, contact the emergency contact should an emergency arise, and contact cannot be made with the primary client, their parents, or spouse.

Limits of Confidentiality

The law protects the privacy of all information obtained during the evaluation process. In most situations, E&E can only release information about the evaluation if the client, parent, or guardian signs a written Release of Information. A Release of Information is specific to an individual, another professional, school or agency. You should be aware that, pursuant to Texas law, test data can only be released to trained mental health professionals.

There are some situations where E&E is permitted or required to disclose information without either a consent or a Release of Information. These include:

1. If a client is involved in a court proceeding and are quest is made for information concerning the client's evaluation, such information is confidential. E&E cannot provide any information without the client's or client's legal representative's written authorization. However, if E&E receives a court order, E&E may disclose information without the client's consent or authorization. If the client is involved in or contemplating litigation, the client should consult his/her attorney to determine whether a court would likely order E&E to disclose information.

2. If the client's records are subpoenaed as part of a criminal investigation, E&E must disclose the client's records without the client's consent or authorization.

3. If a client files a complaint or lawsuit against E&E, E&E may disclose relevant information regarding the client without the client's consent or authorization to defend itself.

There are some situations in which E&E is legally obligated to act. These include:

1. If E&E has cause to believe a child under age 18 has been or is at risk to be abused or neglected (e.g., physical injury, a substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct) or that a child is a victim of a sexual offense, the law requires E&E to make a report to the appropriate governmental agency. This is usually the Texas Department of Family and Protective Services. Once such a report is filed, E&E may be required to provide additional information to this agency.

2. If during an evaluation E&E learns that a client has been sexually abused or exploited by a mental health professional, state law requires E&E to report this information to law enforcement and the professional's licensing board.

3. If E&E determines that there is a probability that the client is in imminent danger of harming himself/herself or others, E&E may contact family members or others (e.g., medical, mental health, or law enforcement personnel) to provide protection for the threatened individuals.

Fee Schedule Agreement

Initial Assessment - $140-$225

Initial interview, collection, and assessment of data Request for records from previous providers

Individual Session

30-minute session (weekly) - $94 - $150 45-minute session (weekly) - $130 - $225

Group Counseling – varies according to group Family Counseling (weekly) - $130 - $225

45-minute session

Marriage Counseling (weekly) - $130 - $225

45-minute session

Marriage Intensive – Contact us for intensive fees and more information

Consultation (schools, parents, agencies, etc.) - $75 - $225

Telephone Consultation (over 10 minutes, not to exceed 45 mins.) - $75 - $225

Telehealth Counseling/Consultation – 45 mins. - $140 - $225

Email Communication (reading and responding to email communication) - $47 - $75 per 15 mins.

Preparation of Documents (work/school/other individual or organization as requested with minimum of 1 week notice) - $140 - $225 per hour

Request of Copy of Records (records sent to individuals/organizations as listed on the Release of Information Form) - $140 - $225 per hour

Legal Fees – Varies by case Session Payments

Therapy sessions are paid via Visa, MasterCard, Discover, American Express, and Health Spending Card. The credit card information is stored securely and is password protected. We charge clients in the morning on the day of their session. Some clients prefer to pay by cash for confidential reasons. Please bring the exact cash amount for your session fee. Charges for unpaid services may be turned over to a collection agency which compromises confidentiality. We do not “carry over” session payments from week to week or extend credit as this could constitute as an unethical “debtor/creditor” dual relationship and ultimately impact the therapeutic relationship.

Fee Increases

Fees are reviewed each year and may increase periodically. Every consideration to a client’s current finances will be made. The increase will be discussed with the client, and a 30-day notice will be given prior to the increase. We will be happy to answer any questions you may have about this fee agreement. Please understand that you have the right to terminate therapy at any point. If you have any questions regarding the fee policy, please do not sign until discussing with your therapist.

The fee for counseling services at Empower and Elevate, have been outlined above. Your signature on this form states you have read and agreed to the fees outlined.

HIPAA and HITECH 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 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 the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment. Your PHI may be used and disclosed without authorization by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members.

For Payment. We may use and disclose PHI without authorization so that we can receive payment for the treatment services provided to you. Examples of payment-related activities are deciding of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose without authorization, as needed, your PHI to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. Finally, 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 WHICH 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:

For my use in treating you.

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.

For my use in defending myself in legal proceedings instituted by you.

For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. Required by law and the use or disclosure is limited to the requirements of such law.

Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

Required by a coroner who is performing duties authorized by law.

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 WHICH 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 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. Any requests must be made in writing and should identify: (i) the information to be restricted, (ii) the type of restriction being requested (i.e., on the use of information, the disclosure of information, or both), and (iii) to whom the limits should apply. If such a request is made, the I am required to accommodate the request, except where I am required by law to make a disclosure.

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 Receive Notification of a Breach. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

8. 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.

VII. Complaints:

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy officer at 10210 Grogan’s Mill Road, Office 194
The Woodlands, TX. 77380 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257.

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 signing this document, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

Informed Consent

The therapeutic relationship is unique in that it is a highly personal and at the same time, 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.

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.

Although our sessions may be very intimate emotionally and psychologically, it is important for you to realize that we have a professional relationship rather than a personal one. Our contact is limited to the scheduled sessions you have with me. Therefore, I will not be able to attend social gatherings with you, accept gifts from you, or have any relationship, other than a professional one, with you. You will learn a great deal about me as we work together during your counseling experience. However, it is important for you to remember that you are experiencing me only in my professional role.

If you ever have any concerns about your therapy process, I encourage you to discuss this with me during our sessions so that we can collaborate as you move forward.

Confidentiality

The law protects the privacy of all information obtained during the counseling process. In most situations, I can only release information about a client, if the client, a parent, or guardian signs a written Release of Information. A Release of Information is specific to an individual, another professional, school, or agency. You should also be aware that, pursuant to Texas law, any test data will only be released to trained mental health professionals. The session content and all relevant materials to the client’s treatment will be 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 himself/herself in a way 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 to render an expert’s report to an attorney.

8. During counseling if I learn that a client has been sexually abused or exploited by a mental health professional, state law requires a report be made to law enforcement and the professional’s licensing board.

Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name. Consultants and employees of Empower and Elevate might consult with each other concerning your care with each other and the owner.

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.

Insurance Policy

Empower and Elevate is considered an out of network provider, some providers in the practice take insurance. Please verify with them and discuss your benefits directly. We often find insurance companies do not cover mental health, limit the sessions (which can influence your progress), and required us to provide a diagnosis. Providing a diagnosis is especially concerning when working with children in a therapeutic setting and we are happy to discuss this with you in the first session. We do accept HSA/FSA spending cards.

We are happy to provide you with billing statement to file with your insurance company on the 1st of each month upon request.

Questions to Help:

To determine if you have mental health coverage, the first thing you should do is check with your insurance carrier. Check your coverage carefully and find the answers to the following questions:

What are my mental health benefits?

What does the coverage amount per therapy session?

How many therapy sessions does my plan cover?

How much does my insurance pay for an out-of-network provider? Is approval required from my primary care physician?

Returning Clients:

Please ask before signing below if you have any questions about psychotherapy or our office policies. Your signature indicates that you have read the following policies and procedures and agree to enter therapy under these conditions. Your signature below indicates that you are making an informed choice to consent to therapy and understand and accept the terms of this agreement.

o Informed Consent for Psychotherapy

o Practice Policies

o Appointments and Cancellations

o Short Notice Cancellations

o No Shows

o Ongoing Cancellations or Multiple No Shows

o Cancellation Policy for Marriage Intensives

o Telephone Accessibility

o Holiday, Weekend, and Evening Contact

o Minors

o Illness Policy

o Termination of Counseling

o Social Media and Electronic Communication

o Sobriety Policy

o Court Related Fees and Services

o Counselor/Therapist Time Off

o Notice of Privacy Practices (HIPPA)

o Insurance Policy

o Emergency Contact

o Credit Card Authorization

o Fee Schedule Agreement

o Divorce Information Regarding Children

o Parent Consent for child under 18

o Referral of Friends, Family, Co-Workers

o Evaluations

I have read, signed, and agree to the terms outlined in the complete paperwork packet of policies and procedures, provided either electronically or in paper form.

Practice Policies & General Information

The standard meeting time for psychotherapy is 45 minutes. Appointments and Cancellations

At Empower and Elevate, you can always expect to start out with weekly counseling sessions. Counseling is most effective when done on a consistent basis. Towards the end of your treatment your counselor will discuss a transition with you to every two weeks until final termination.

We understand that our clients sometimes need to cancel their appointments. Please let us know of any appointments you are unable to keep. Our clients may miss two appointments every six months without charge by giving us 48 hours’ notice. Additional missed sessions and/or sessions missed without 48 hours’ notice are charged at the usual session rate. A client must also reschedule their appointments prior to 48 hours of the appointment time to avoid incurring a charge for the original appointment. Appointments that fall on public holidays are not chargeable, and you will not be charged for appointments during your therapist’s absence.

This policy is strict and 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.

If your therapist is unable to attend your therapy session (outside of scheduled vacations) due to an emergency or illness, every attempt will be made to contact you immediately and you will not be charged a session fee.

Short Notice Cancellations

Appointment cancellations made less than **48 hours** before the scheduled appointment will be charged the full agreed upon fee for the session.

No Show

If you do not show up for a scheduled appointment (that you have not called to cancel) you will be charged the full fee for the session. If you tend to forget appointments, please let us know – we will be happy to email you in advance to confirm your sessions. However, you are responsible for keeping track and attending your sessions.

Ongoing No Shows or Multiple Cancellations

It is understandable that occasionally an appointment will be cancelled or missed due to illness or emergency. However, your regular session day/time has been reserved for you. Our current client schedule and wait list does not allow for a great deal of flexibility with respect to continual cancellations, rescheduled appointments, or no shows. If you find that your schedule is no longer able to accommodate the session time reserved for you, please discuss this with your therapist. Please note that should ongoing cancellations, frequent reschedules (even those within the same week), missed appointments, late payments/nonpayment become an issue, your therapist will discuss this with you. If after discussing other options with you your attendance has not changed, we will need to open your reserved time to the wait list and add you to the wait list. If you prefer not to be placed on the wait list, then we will provide you with three therapy referrals and/or terminate with you.

Telephone Accessibility

If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. If a true emergency arises, please call 911 or any local emergency room.

Holiday, Weekend, & Evening Contact

Your counselor will make every effort to return a call, email, or text message of a non-emergency client message within 24 hours during office hours. If this call, text, or email arrives during a holiday, weekend, or evening, your therapist will return the non-emergency client contact during the first working day following the holiday, weekend, or evening. For emergency only clients (emergency constitutes imminent danger to self or others) your therapist will make every effort to return the call, text, or email within 24 hours and ask that if the client is facing a life-threatening emergency that they call 911 immediately. There will be a regular session fee for emergency and non-emergency phone calls and sessions that are more than 5 minutes, or more than 1 time per month.

Minor

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. It is our policy that any child aged 12 and younger have a parent or adult guardian remain onsite for the entire counseling session.

Illness Policy

When a private practice counselor is consistently exposed to cold and flu viruses in the office and becomes ill as a result, the office closes, sessions, and groups are cancelled, and everyone suffers. To maintain good health and create a safe and relatively germ-free environment so that we can support all our clients, we ask that clients who are experiencing any stage of illnesses to respect safety boundaries and to cancel the appointment (see cancellation policies) until they are recovered completely and are not experiencing any signs of illness, fever, rash or cough or contagious symptoms at any stage. Your counselor will extend the same respect and consideration if we are ill. If you choose to show up for your counseling session, couples’ session, or group session at any stage of a contagious flu virus or other illness, your counselor will use discretion, will uphold safety boundaries, and might ask you to leave the office, and the session fee will be charged. On the rare occasion that an emergency or grave illness occurs that does not allow you to give 48 hours’ notice, special consideration will be extended.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination appointment if I determine that the psychotherapy is not being effectively used or if 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 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, I must consider the professional relationship discontinued.

For clients that utilize extended breaks between appointments or utilize therapy on an as needed basis: After 4 weeks of not holding a current appointment or having a future appointment scheduled, you are considered a previous client and your case will be closed. However, you are always welcome to re-engage in the therapy process, this policy is enforced to honor legal and ethical concerns within our field.

Referrals of Friends, Family, Co-Workers

The greatest compliment, a counselor can receive are referrals from current or former clients. There are times when clients wish to introduce their counselor so they can make a recommendation as a referral, which is ethical and acceptable. Please understand that your confidentiality is extremely important to us. If another client that we see referred you to us, or if you refer a friend, co-worker, or family member to Empower and Elevate, legally and ethically your counselor is not able to acknowledge that other person’s attendance to you if they should begin seeing us in counseling or if they are currently in counseling with us.

If you choose to share that your Empower and Elevate counselor is also your counselor with the person who referred you or with someone you refer, that is a decision that you must make if you choose to reveal you are in counseling with Empower and Elevate.

Please be assured that the counselors at Empower and Elevate will not acknowledge you as a client to anyone outside of Empower and Elevate without your written consent, or unless mandated by a court of law. Occasionally we may discover through something you share in a session that we have seen/are seeing someone that you know in counseling. If this is the case, your counselor must maintain that person’s confidentiality as well, and will hold this information just as he or she would uphold your confidentiality.

On occasion a client may say, “My friend Jane/John Doe mentioned that she/he started seeing you and is enjoying the work you are doing with him/her.” This is an example of our standard response which is stated in a kind tone: “I appreciate any referrals clients make; however, I cannot reveal who I see in counseling, and thus I cannot remark on who I see clinically at this time.”

Because this may sound rather official to clients, and because Empower and Elevate will not acknowledge who is seen in counseling, including you, we thank our clients here on this page in advance for any referrals they may make: Thank you for the referral; We are honored by your trust and confidence.

Sobriety Policy

We ask that all clients, couples, families, and group members arrive to therapy sober and not under the influence of drugs and/or alcohol. If your therapist notices that you are intoxicated (such as slurred speech, rapid speech, smelling of alcohol, behavior that indicates intoxication with cocaine, prescription drug abuse, marijuana, or other substances) the therapy session will be immediately terminated. We will also assist you in finding a safe ride home (via friend, family member or taxi) as driving while under the influence constitutes a risk to others and is a reportable offense. Once you are safely home, your therapist will reschedule the therapy session where this occurrence will be processed.

You will be charged your full fee for the session if you arrive intoxicated.

Social Media & Electronic Communication

This document outlines our office policies related to use of social media. Please read it to understand how we conduct ourselves on the Internet as mental health professionals and how you can expect us to respond to various interactions that may occur between client and counselors on the Internet. If you have any questions about anything within this document, I encourage you to bring them up when you meet with your counselor. As new technology develops and the Internet changes, there may be times when this policy needs to be updated. If I do so, you will be notified in writing of any policy changes. You are welcome to follow our E&E business pages to receive psycho-education, however, we cannot engage in any form of correspondence to protect your confidentiality. If you need to reach your provider please email them for any concerns.

Email and Text

Email and texting should only be used to arrange or modify appointments. Please do not email/text content relate to your therapy sessions, as email/text is not completely secure or confidential. If you choose to communicate with us by email/text, be aware that all emails/texts are retained in the logs of 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. You should also know that any emails/texts we receive from you and any responses that we send to you become a part of your legal record. There is a HIPPA compliant email service to communicate with our counselors in your client online account.

Friending

Several of our counselors hold both personal and professional accounts on various social media outlets. On our personal accounts, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Instagram, etc.). We 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 you meet with your counselor. You may, however, like or join our professional pages, such as on Facebook, Twitter, Instagram, Pinterest, etc. The links to our professional sites can be located off our main website https://empowerandelevate.net. We often post information you might find useful.

Social Media Conclusion

Thank you for taking the time to review our Social Media 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 our attention so that we can discuss them.

Telehealth Consent

Telehealth is a HIPPA compliant video-counseling service provided by Empower and Elevate, LLC. This video-conferencing counseling option will be conducted through Simple Practice, the secure therapy service.

When providing Telehealth services your counselor will be in a private, well lit, room using a secure internet connection. Your counselor will explain how the Telehealth consultation is performed and how it will be used for your treatment. Your counselor will also explain how the consultation(s) will differ from in-person services, including benefits and limitations of the technology.

By consenting to receive Telehealth services you acknowledge the following:

1. My counselor may only conduct Telehealth sessions with me only while I am in the state of Texas.

2. The laws that protect the confidentiality of my medical information also apply to Telehealth. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards oneself or others; and where I make my mental or emotional state an issue in a legal proceeding.

3. I understand that, while this is a HIPPA compliant service, there are potential risks and consequences from Telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my counselor, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that Telehealth based services and care may not be as complete as face-to-face services. I also understand that if my counselor believes I would be better served by another form of counseling services (e.g., face-to-face services) I will be referred to a counselor who can provide such services in my area.

4. I understand that my counselor can discontinue the Telehealth sessions if it is felt that the video conferencing connections are not adequate for the situation.

5. I must provide my counselor will an updated location for emergency purposes at the start of each Telehealth session, as well as a predetermined verification of identity code.

6. I will need access to, and familiarity with, the appropriate technology to participate in the service provided.

7. I understand that my counselor will conduct Telehealth sessions from a private and secure space to ensure a reasonable degree of confidentiality, but that he/she does not control my physical location.

8. I understand that I have the right to withhold or withdraw my consent of the use of telemedicine during my care at any time, without affecting my right to future care or treatment.

I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent Empower and Elevate, LLC providing health care services to me via Telehealth.

Parental Consent Form

If my child listed in this electronic record, has my permission to participate in the counseling services provided by Empower and Elevate, LLC. I understand that all materials (interview information, test scores, audio/video tapes, and other personal data) will remain confidential and will not be released to any other agency or person without my/our written consent, unless in cases of child abuse and court orders.

If your child is part of a divorce, custody case, adoption, or foster care a copy of the decrees showing who has the rights to obtain psychological treatment MUST BE ON FILE PRIOR TO TREATMENT.

I hereby consent to allow the above-named person to participate in these counseling services, this does not waive any of my/our legal rights.

Eye Movement Desensitization and Reprocessing (EMDR) Treatment:

EMDR is a simple but efficient therapy using bilateral stimulation (BLS) ─ tapping, auditory tones or eye movements ─ to accelerate the brain's capacity to process and heal a troubling memory. BLS, which occurs naturally during dream sleep, causes the two brain parts to work together to reintegrate the memory. Some clients experience relief or positive effects in just a few sessions. EMDR is effective in alleviating trauma-related symptoms, whether the traumatic event occurred many years ago or yesterday. It gives desired results –with little talking, without using drugs, and requires no “homework” between sessions.

Scientific research has established EMDR as effective for the treatment of post traumatic stress, phobias, panic attacks, anxiety disorders, stress, sexual and physical abuse, disturbing memories, complicated grief and addictions.

The possible benefits of EMDR treatment include the following:

-The memory is remembered but the painful emotions and physical sensations and the disturbing images and thoughts are no longer present.

-EMDR helps the brain reintegrate the memory and store it in a more appropriate place in the brain. The client’s own brain reintegrates the memory and does the healing.

The possible risks of EMDR treatment include the following:

-Reprocessing a memory may bring up associated memories. This is normal and those memories will also be reprocessed.

-During the EMDR, the client may experience physical sensations and retrieve images, emotions and sounds associated with the memory.

-Reprocessing of the memory normally continues after the end of the formal therapy session. Other memories, flashbacks, feelings and sensations may occur. The client may have dreams associated with the memory. Frequently the brain is able to process these additional memories without help, but arrangements for assistance will be made in a timely manner if the client is unable to cope.

As with any other therapeutic approach., reprocessing traumatic memories can be uncomfortable; that means, some people won’t like or be able to tolerate EMDR treatment well. Others need more preparation, offered by the therapist, before processing traumatic events using EMDR.

-There are no known adverse effects of interrupting EMDR therapy; therefore, a client can discontinue treatment at any time.

-Alternative therapeutic approaches may include individual or group therapy, medication, or a different psychotherapy modality.

-EMDR treatment is facilitated by a licensed psychotherapist having EMDRIA-approved training.

HISTORY AND SAFETY FACTORS

The client must …

-Be willing to tell the therapist the truth about what he/she is experiencing.

-Be able to tolerate high levels of emotional disturbance, have the ability to reprocess associated memories resulting from EMDR therapy, and to use self control and relaxation techniques (eg. calm place exercise).

-Remember debriefing instructions and call his/her therapist, connect with supportive family or friends, or use meditation or other techniques (eg. calm place exercise) he/she has agreed to therapy, if needed.

-Disclose to therapist and consult with his/her physician before EMDR therapy if he/she has a history of or current eye problems, a diagnosed heart disease, elevated blood pressure, or is at risk for or has a history of stroke, heart attack, seizure, or other limiting medical conditions that may put him/her at medical risk.

-Inform the therapist if he/she is wearing contact lenses and will remove them if they impede eye movements due to irritation or eye dryness. The therapist will discontinue bilateral stimulation (BLS) eye movements if the client reports eye pain and use other dual stimulation (tapping, sounds) to continue reprocessing.

-Assess his/her current life situation to determine EMDR approach. Clients may need the ability to postpone demanding work schedules immediately following the EMDR session.

-Before participating in EMDR, discuss with the therapist all aspects of an upcoming legal court case where testimony is required. The client may need to postpone EMDR treatment if she/he is a victim or witness to a crime that is being prosecuted because the traumatic material processed using EMDR may fade, blur or disappear and her/his testimony may be challenged. understand disagreements with family and/or friends may occur as she/he learns new skills such as assertiveness or social skills after processing problems and disturbing material using EMDR. Vulnerable clients may need to be protected.

-Be willing to explore the issues(s) that may arise as change occurs. For example, changes regarding your identity; finances; loss of identification with a peer group; and/or attention.

-Consult with his/her medical doctor, before utilizing medication. Some medications may reduce the effectiveness of EMDR. For example, benzodiazepines may reduce effectiveness possibly due to state-dependent processing and/or regression may occur after ceasing antidepressants.

-Address with the therapist his/her ability to attend to EMDR due to recent cocaine dependence, long term amphetamine abuse, seizures, and/or other neurological conditions. EMDR is contraindicated with recent crack cocaine users and long term amphetamine users.

-Discuss with the therapist any Dissociative Disorders; Dissociative Identity Disorder unexplained somatic symptoms, sleep problems, flashbacks, derealization and/or depersonalization, hears voices, unexplained feelings, memory lapses, multiple psychiatric hospitalizations, multiple diagnoses with little treatment progress - EMDR may trigger these symptoms.

I HAVE READ AND I UNDERSTAND THE POSSIBLE OUTCOMES OF EMDR LISTED ABOVE AND UNDERSTAND I CAN END EMDR THERAPY AT ANY TIME. I AGREE TO PARTICIPATE IN EMDR TREATMENT AND I ASSUME ANY RISKS INVOLVE IN SUCH PARTICIPATION.

E&E Dissolution

This type is triggered by uncontrollable external factors, such as bankruptcy or even the death of a member: "In the event of the death, retirement, expulsion, bankruptcy, or insolvency of any Member, the LLC will dissolve as per Texas Law". If this was to occur you will be sent information on how to access previous records if needed.

By signing this agreement, you give E&E express permission to take all the above actions. While this written agreement of exceptions to confidentiality should be helpful in informing you about potential problems, it is important that any questions or concerns be discussed. E&E reserves the right to seek legal advice if a question should arise regarding disclosure of confidential information that E&E is unable to answer on its own.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.