PART 1: CONFIDENTIALITY 

Anything said in therapy is confidential and may not be revealed to a third party without written authorization,except for the following limitations: 

Child Abuse (Florida Statute 39.201). Child abuse and/or neglect, which include, but are not limited to, domestic violence in the presence of a child; child on child sexual acting out/abuse; physical abuse, etc.(If you reveal information relative to child abuse or child neglect, I am required by law to report this to the appropriate authority.

Vulnerable Adult Abuse or Neglect (Florida statute 415.1034) If you reveal information of vulnerable adult or elder abuse, I am required by law to report this to the appropriate authority.

Self-Harm (Florida statute 491.0147and Chapter 394): If you threaten or reveal plans or attempt to harm yourself in any way, I am permitted under such instances to take steps to protect your safety which may include the disclosure of confidential information. 

Threats of Harm to Another person or persons (Florida statute 491.0147):  If you threaten bodily harm or death to another person, I am permitted by law to report this to the appropriate authority.

Court Orders & Legal Issued Subpoenas: If I receive a subpoena for you records, I will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information. I will contact you twice by phone.  If I cannot get in touch with you by phone, I will send you a secure, confidential email or letter by USPS. If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in the order. Despite any attempts to contact you and keep your records confidential, I am required to comply with a court order.  Please note that I will charge $125.00 per hour to follow up with a Court Order or Subpoena.  A Summary Letter to Comply with a Records Request is $500 and will be payable prior to the Release of Records. I cannot submit an invoice to any attorney and wait for payment at the end of a case, which could take a few years.  Insurance will not cover these costs. Court Appearances will cost $500 per day, payable in advance.

Written Request:  In the case of notes documenting or analyzing the contents of conversation during a private counseling session ("process notes"),I reserve the right to provide to you or the authorized third party a report of examination or treatment in lieu of copies of the actual records, unless the third party is a treating psychotherapist (Florida Statute 456.057and HIPAA Privacy Rule). If therapy sessions involve more than one party, ALL parties over the age of 18 MUST consent to release of requested information prior to information being released.

Dual Relationships: It is imperative that we do not have any relationship outside the counseling relationship such as friendship, business, or social relationships. If we have a contact in a public setting, I will not acknowledge you in anyway that would jeopardize your confidentiality. Should you choose to acknowledge me, I may not be able to protect your confidentiality.

Social Media: If you choose to connect with me on any of my professional (not personal) social media outlets such as Facebook, Linkedin, Pinterest, Instagram, or Twitter, you do so at your own risk. I will do my best to protect your identity. However, if you choose to comment on my pages or posts, you do so at your own risk and I cannot be held liable if someone identifies you as a client.

Electronic Communication: Email offers an easy and convenient way for therapist and client to communicate, but can also introduce unique challenges into the therapist-client relationship. Be aware some guidelines for contacting me using email. Do not use email for emergencies. If it's an emergency, consult with an emergency room. Email is not a substitute for seeing me. If you think that you might need to be seen, please call and schedule an appointment. Email should not be used to communicate sensitive medical or mental health information. Email is not confidential. Be aware that if you send an email from your work, your employer has the legal right to read your email. E-mail will become a part of your record. Further, texting also introduces some of the same challenges. Like email, it is not a substitute for seeing me or making an appointment. Texting is not confidential. Phones can be lost or stolen, so it is imperative that you do not communicate information of a sensitive nature over a text. Further, I cannot know the person who is texting is actually you, rather than another person who has possession of your phone.  If you wish to communicate with me concerning any of the above issues, secure HIPPA compliant messaging and email are available for your use in your private client portal. 

PART 2: THERAPEUTIC PROCESS BENEFITS/OUTCOMES:

Participating in therapy can result in numerous benefits, including improving intrapersonal and interpersonal relationships, resolving the concerns that led you to therapy. Therapy will seek to meet goals established by all persons involved, usually revolving around a specific complaint(s). A major benefit that may be gained from participating in therapy includes a reduction in distress and a better ability to handle or cope with personal, relational, family, work, and other problems as well as stress. Another possible benefit may be a greater understanding of personal and relational goals and values; this may lead to greater maturity and happiness as an individual and increased relational harmony. Other benefits relate to the probable outcomes resulting from resolving specific concerns brought to therapy. I will do my best to assess progress on a regular basis and solicit your feedback regarding the therapeutic process to help provide you with the most effective therapeutic services. I can make no guarantees as to the ultimate outcome of therapy. 

EXPECTATIONS: Work outside of the counseling sessions is an essential aspect of change. I may assign tasks between sessions related to your goals. My commitment is to work as efficiently as possible,but at the same time, therapy may move more slowly than you anticipated. We will collaborate to identify your therapeutic goals and will periodically review your progress toward them.

RISKS: In working to achieve these potential benefits,the therapeutic process requires that actions be made to change and may involve experiencing discomfort.Therapeutically resolving unpleasant events and relationship patterns may arouse intense, unexpected feelings. Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended.We will work together for a desirable outcome; however, there is a possibility that the goals of therapy will not be met.We will review your progress at regular intervals and modify our treatment plan as needed. 

PART 3: STRUCTURE OF THERAPY 

INTAKE PHASE:  We will discuss the process, structure, policies and procedures of therapy.This occurs during the 1st session. We will need to spend some time exploring your experiences both surrounding the presenting complaint(s) and outside the realm of your complaint(s). During this session we will also review the Therapy Agreement, Policies and Consent for Services

ASSESSMENT PHASE:  This phase will take approximately 2-4 sessions.  the assessment phase I am getting to know and understand you,your worldview, strengths, concerns, needs, family and relationship dynamics,etc. During this phase I am gathering a lot of information and it may not feel like we are moving forward, but it is imperative for me to gather this information to assist you the best I can. During this time,we both decide if I am the best person to provide therapeutic services for your specific needs. If you or I determine that I am not the best person to address your needs and treatment plan, then referrals will be made for a more appropriate treatment provider.

GOAL DEVELOPMENT & TREATMENT PLANNING: After we have explored and developed sufficient background to proceed,we will collaboratively identify specific goals for therapy.Therapy is best concluded through mutual agreement among the participants,including myself as your therapist, and will be directly tied to sufficient progress toward and/or the achievement of the goals we set together.

INTERVENTION PHASE:  This occurs anywhere from session until graduation/discharge/termination.This phase requires effort both in session and completing any agreed upon assignments outside of session.You will maximize therapy by implementing solutions discussed during session.During this phase we will review your progress and make any adjustments to your goals as needed.If at anytime you have questions about what I am attempting to do or where we are headed, please do not hesitate to ask.

Discharge:  As you progress and get close to completing your goals, we will collectively discuss your progress, and decide on the date of discharge

LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for 1 hour.  A clinical hour is 50 minutes. It is difficult to initially predict how many sessions will be needed, but we will collaboratively determine from session to session how much longer therapy is recommended.

PART 4:  HEALTH INSURANCE

By using insurance I am required to give you a mental health disorder diagnosis that goes on your medical record. I am not required to tell you what I am diagnosing you with but as best practice it is my policy that we collaborate on this information.You may have had a previous diagnosis from another treatment provider. After my assessment, if I clinically determine that you have the same diagnosis I will use that diagnosis. If I assess you and clinically determine otherwise I will discuss that information with you before providing you with either a new diagnosis or secondary diagnosis. It is also important to note that some psychiatric diagnoses are not even eligible for reimbursement.This is often true for marriage/couples and family therapy as well.In the event of non-coverage or denial of payment,you will be responsible to pay for such services. In the event of non-payment by you, Jaye L Anderson LCSW LLC  reserves the right to seek payment of unpaid balances by collection agency of legal recourse after reasonable notice to you.Your insurance company will also know the times and dates of services provided. At times insurance companies may request further information to authorize further services regarding your treatment.

PREAUTHORIZATION AND REDUCED CONFIDENTIALITY: When visits are authorized, usually only a few sessions are granted at a time.When these sessions are finished, your therapist may need to justify the need for continued service potentially causing a delay in treatment. Sometimes additional sessions are not authorized, leading to an end of the therapeutic relationship even if you do not feel you have achieved your therapeutic goals.Your insurance company may request or require additional clinical information that is confidential in order to approve or justify a continuation of services. The information they may request may include treatment plans, progress notes, and at times the entire medical record is requested. I cannot assure or guarantee your confidentiality when an insurance company requires this information.Even if the therapist justifies the need for ongoing services your insurance company may decline services regardless if you think you need continued therapy or not. You are at the mercy of your insurance company to decide your care. You should be aware that some of your personal information might be added to national medical information data banks. For these and other reasons, many therapists openly talk about "the myth of confidentiality" when ever insurance companies become part of the therapeutic process.

POTENTIAL NEGATIVE IMPACTS OF A DIAGNOSIS:  Insurance companies require the therapist to give you a mental health diagnosis (i.e.,"major depression" or "obsessive-compulsive disorder") in order to get reimbursed. Psychiatric diagnoses may come back to negatively impact you in the following ways:  1.Denial of insurance when applying for disability or life insurance; 2. Company (mis)control of information when claims are processed; and, 3. Loss of confidentiality due to the increased number of persons handling claims.

PART 5: CONSENT FOR SERVICES: 

I have read and understand the information contained in the consent and therapy agreement. I have discussed any questions that I have regarding this information with JAYE L ANDERSON LCSW. My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent. I authorize JAYE L ANDERSON LCSW to provide counseling services that are considered necessary and advisable.

RELEASE OF INFORMATION TO INSURANCE COMPANY: I authorize the release of my treatment and diagnosis information (as described in Part 4, above) necessary to process bills for services to my insurance company,and request payment of benefits to JAYE L ANDERSON LCSW. I acknowledge that I am financially responsible for payment whether or not covered by insurance. Additionally, I acknowledge that I, and not my insurance company,will be responsible for fees associated with appointments cancelled within less than 24hours. I understand, in the event of nonpayment of fees not covered by insurance,JAYE L ANDERSON LCSW LLC may utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney.

PHONE CONTACTS AND EMERGENCIES:  Office hours are from 9:00AM to 6:00PM, Monday through Thursday. The office is closed on Friday, Saturday and Sunday.  If you need to contact me, please call 561-308-9818, leave a voicemail, and I will get back to you within 24 hours or, if outside of normal business hours, the next business day.  In emergency situations, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255 or dial 911 if either you or someone else is in danger of being harmed.  You can also contact the Palm Beach County Help Line for assistance by dialing 211, or texting the word HOME to 741741, any time 24 hours a day, 7 days a week.  

This form is in addition to the regular Therapy, Policies, Agreement and Consent Form you have previously signed.  You must sign both in order to participate in Telehealth Video Sessions (TVS) video counseling only.  TVS will be accessible through your Private Client Portal.  The Video Platform meets all HIPPA requirements and is a secure connection and will maintain confidentiality.  You will be able to access your portal and video session utilizing your Smart Phone; Tablet; Laptop and Desktop PC or MAC.

This Consent and Agreement is to inform you about what you can expect regarding your participation in TVS. 

Benefits: The benefits to TVS counseling are: 1. The ability to expand your choice of service provider; 2. More convenient counseling options including location, time, no driving, etc.; and, 3. Increased availability of services to homebound clients, clients with limited mobility, and clients without convenient transportation options.

Limitations:  It is important to note that there are limitations to TVS counseling that can affect the quality of the session(s). 

These limitations include but are not limited to the following: 

1. I cannot see you, your body language, or your non-verbal reactions to what we are discussing.

2. Due to technology limitations, I may not hear all of what you are saying and may need to ask you to repeat things.

3. To reduce the effect of these limitations, I may ask you to describe how you are feeling, thinking, and/or acting in more detail than I would during a face-to-face session. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.

Logistics:  When I provide video-counseling sessions, I will call you at our scheduled time or send you link for our secure and HIPAA compliant video session.  I expect that you are available at our scheduled time and are prepared, focused and engaged in the session.  I am calling you from a private location where I am the only person in the room.  You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality.  If you choose to be a in a place where there are people or others can hear you, I cannot be responsible for protecting your confidentiality.  Every effort MUST be made on your part to protect your own confidentiality.  I suggest you wear a headset to increase confidentiality and also increase sound quality of our sessions.  Please make every effort to reduce all possibilities of interruptions for the duration of our scheduled appointment.  Per the State of Florida licensing board and ethical guidelines, I can only practice in the State of Florida. That means you must also reside in the State of Florida.  If you move outside of the State of Florida, you agree to inform me prior to your change of residence.

During Video Sessions:  If we lose our connection during a video session, I will call you to troubleshoot the reason we lost connection.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss due to technology, battery dying, bad reception, etc. that occurs on your part, you will still be charged for the entire session.  If the loss for connection is a result of something on my end, we can either complete our session via. phone or plan an alternate time to complete the remaining minutes of our session. 

Recording of Sessions:  Please note that recording, screenshots, etc. of any kind of any session is not be permitted and is grounds for termination of the client-therapist relationship.

Payment for Services: Payments for services must be made at the time of your session.  I will process your payment on the credit card information on file with the exception of EAP clients wherein the EAP company will be reimbursing therapist for EAP sessions.

Emergencies:  If a situation occurs where we are talking and get disconnected and you are in crisis, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 800-784-2433.  You can also text the crisis line 24/7 at 741741 and speak with a crisis line counselor.  If I have concerns about your safety at any time during a phone session, I will need to break confidentiality and call 911 (if located in the same county or emergency services in the area you are located at the time of the call) and/or your emergency contact immediately.  Please note that everything in our informed consent for Services that you signed, including all the confidentiality exceptions, still applies during phone/video sessions. 

Consent to Participate in Telehealth Video Sessions:  By signing below you agree that you have read and understand all of the above sections of TVS informed consent.  You agree that you also understand the limitations associated with participating in TVS counseling sessions and consent to attend sessions under the terms described in this document. 

This Agreement sets forth my policy for my all fees, appointments and cancellations.  You are responsible for attending each scheduled appointment and agree to adhere to the following:

FEES: My fee for each session is $125.00 per 50-minute session. Payment is due at the time of the session in the form of cash, check, credit/debit card, or HSA/FSA cards.  If you pay by check, please note that you are responsible for any bank fees associated with checks returned for insufficient funds, or for any other bank fees incurred as a result of your check not honored by your financial institution.  If your check is returned and not honored by your financial institution, I will no longer accept any payment by check.

ADD-ON SERVICES:  All costs for services outside of your scheduled session will be billed and payment due at the beginning of your next scheduled session. I charge my hourly rate of $125.00 prorated in quarter hours (15 minute increments) for phone calls, email correspondence, reading assessments or evaluations, writing assessments or letters, and collaborating with necessary professionals (with your permission) for continuity of care.  Please note that these type of fees incurred will not be covered by your insurance company.

CANCELLATION OF APPOINTMENTS: If you are prevented from keeping a scheduled appointment, you MUST notify me 48 hours in advance. I send out a text reminder 48 hours prior to your appointment, however, please note that technology is not always perfect and it is your responsibility to keep track of your scheduled appointments.  If I do not receive a 48-hour advance notice, you will be responsible for paying a late cancellation fee in the amount of $50.00, and that fee cannot be billed to your insurance company.  I will process your credit card on file for the amount of the session on the same day. I reserve the right to terminate our counseling relationship if more than 3 sessions are missed with or without proper notification.

NOW SHOW POLICY:  If you are 15-minutes late for an appointment, your appointment will automatically be cancelled and you will be charged $50.00 and considered as a No Show for your appointment.  

EMERGENCIES:  There are always exceptions to the above policies that will arise such as:  sudden illness, unexpected family emergency, or work related issue.  In this event, please contact me immediately by telephone. Please do not text or email and I will do my best to accommodate said emergencies.   

TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion a court will order a therapist to testify, be deposed, or appear in $500.00. Said rate will include, but is not limited to: travel to and from the courthouse, time in court, waiting for the court hearing, preparation for documents, etc. A proposed invoice will be drawn up and you will be required to pay prior to the appearance. I will not submit an invoice to your attorney for payment at the end of your case.  Any amount that is due to Jaye L Anderson LCSW LLC, or needs to be returned to you after the appearance, will be due/returned within 2 calendar weeks.

COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records they will be dispensed at $1.00 per page. Payment for your medical records will be due prior or upon receipt of them and can be picked up at my office please allow at least 2 weeks to prepare your records. If you are not able to pick up your records, I will also charge you for the postage.  You will also need to sign a release for medical records to be dispensed to either you or designated party, and I reserve the right to provide a summary letter of progress notes.

FEE DISPUTES: In the case of a credit card dispute, I reserve the right to provide the needed and adequate documentation that covers the cancellation policy to your bank or credit card company should you dispute a charge that you are financially responsible for. If you have a financial balance, you will be sent a bill to the home address on file form unless you advise me otherwise.  If the credit card company determines that the charges are deemed in order and just, you agree to pay for any and all charges I incur as a result of defending those charges.