DISCLOSURE AND POLICY STATEMENT

ACKNOWLEDGEMENT & CONSENT

Welcome!  I am pleased to have the opportunity to work together.  I am an independently licensed clinical social worker, practicing with other clinicians under the name The Biltmore Wellness Collective.  This is an association of independently practicing professionals which shares certain expenses and facilities.  While the members share a name and office space, we are completely independent in providing clinical services.  Professional records are separately maintained and no member of the group can have access to them without your specific, written permission. 

This document contains important information about my professional counseling/therapeutic services and business policies, including my background, treatment offered, fees, cancellations, and treatment agreement(s), which you must read and sign to in order to participate in treatment. 

The purpose of this information is to help you make an informed decision about participating in treatment. Please read it carefully. Bring any questions you might have so we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us and a copy of your signed Disclosure and Policy Statement Acknowledgement and Consent is always available upon request.

Therapeutic Orientation and Behavioral Health Services

I provide individual and family therapy for children and families. I work from a strength based perspective and like to understand the individual in context of his/her environments, relationships, culture and experiences.   I use primarily solution focused therapies but consider client preference/needs when making treatment plans. I will thus spend several sessions gathering information and getting to know a client before outlining a treatment plan.  Concurrently, the client can use this time to get to know me and decide if it is a comfortable working relationship.  

The nature of the therapeutic relationship will depend on the individual.   When a child or adolescent is the primary client, treatment may also encompass working with the family.  In order for children and adolescents to make changes it is sometimes necessary for parents to promote change at home and/or within themselves.  This can be challenging and uncomfortable.  Throughout the process, however, I will support the family and continually discuss resources for helping with adjustment.  

The ultimate goal is for the client to evidence stronger self, better relationships and solutions to problems.  While this may be difficult at times, it can be a rewarding experience that promotes self-efficacy and positive sense of accomplishment. All clients have certain rights associated with psychotherapy and/or their treatment plans. Clients have the right to ask questions about and/or refuse any suggested technique or recommended treatment and the right to be advised of the consequences of such refusal or withdrawal. Clients have the right to end therapy at any time, without any moral, legal or financial obligations other than those already accrued. Upon request, I may provide clients with the names of other qualified individuals. Clients have the right to participate in treatment decisions and in the development and periodic review and revision of your treatment plan (as further discussed below). 

The first few sessions will involve an evaluation of the client needs. By the end of the evaluation, I will be able to offer the client some first impressions of what the work will include and a treatment plan will follow. The treatment plan will be discussed with the client and/or family. Each client should evaluate this information and consider their own opinions of whether they feel comfortable working with me. Please note, we will review any treatment plan in place periodically, but no less than once per year, to assess the progress and/or update as appropriate. Therapy involves a large commitment of time, money, and energy, so each individual should be very careful about the therapist they select. If and as there are questions about my procedures, the treatment plan, or any of these policies, we should discuss them immediately, as they arise.  

Telehealth 

Please be advised that in certain circumstances, such as COVID-19 pandemic and CDC recommendations, I may offer my client’s the option to have appointments conducted via telehealth.  All clients are required to review these Telehealth policies in order to proactively prepare for online sessions, in the event they occur. Telehealth fees are the same as for in-person sessions; provided however, if there is a technological failure disconnecting a session and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. It is the client’s responsibility to ensure that their health insurance plan covers telehealth. If the client’s insurance does not cover telehealth, the client will be solely responsible for the entire fee of the session. We advise that each client contact their insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Please read this carefully and let me know if you have any questions. 

Telehealth refers to providing health services over the internet using videoconferencing. One of the benefits of telehealth is that the we can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or I am unable to continue to meet in person. It is also more convenient and may take less time. Telehealth, however, requires technical competence on both parts. Although there are benefits of telehealth, there are some differences between in-person and online services, as well as some risks. For example: There are risks to confidentially. Because telehealth sessions take place outside of my private office, there is potential for other people to overhear sessions if the client is not in a private place during the session. On my end, I will take reasonable steps to ensure a client’s privacy. It is important for the client to make sure they find a private place for their session where we will not be interrupted. It is also important for to protect the privacy of our session on your cell phone or other device. The client should participate in the session only while in a room or area where other people are not present and cannot overhear the conversation. There can be issues related to technology. There are many ways that technology issues might impact telehealth, such as technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. There can be risk associated with crisis management and intervention; however, I usually will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, I will determine if our meeting is appropriate for telehealth and inform you of any concerns. There may be efficacy risks. Most research shows that telehealth is almost as effective as in-person care. However, some providers believe that something is lost by not being in the same room. For example, there is debate about a provider’s ability to fully understand non-verbal information when working remotely.  

Please note, the client is solely responsible for any necessary equipment, accessories, or software needed to take part in telehealth. If the client does not have the proper internet access or equipment, please inform me in advance so that we can consider other options.  If the session is interrupted, we should both disconnect from the session. We will both wait two (2) minutes and then attempt to reconnect. If either of us is absent from the videoconference after those two (2) minutes, please call or text me at 425.588.9280.  

Arizona State law allows for the practice of telehealth between a qualified healthcare professional and a client at home or in another private location, so long as the client is within the state of Arizona. If a client moves out of state or is temporarily out-of-state, telehealth is not permitted. Note that the videoconferencing service that I use will log the client’s physical location based on your internet signal, providing evidence the client was in Arizona at the time of the session.  

I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of any telehealth session. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications.  The client should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth).  Note that the confidentiality and the exceptions to confidentiality outlined below and within the Notice of Privacy Practices apply to telehealth. No telehealth sessions shall be recorded in any way unless agreed to in writing by mutual consent and I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies

Doxy.me is the videoconferencing service that I use for telehealth sessions. Doxy.me is a secure, encrypted videoconferencing service that allows for secure conversations. It meets HITECH and HIPAA standards.  In the event of a telehealth appointment, the client will receive a separate document with instructions and a link for the session.  Please see the Telehealth Addendum, attached to this Disclosure and Policy Statement Acknowledgement and Consent for additional details related to the technology required and other relevant telehealth information. 

Education and Training

I have been in the mental health field for over 25 years and have experience with diverse clientele and issues.  I earned a Master of Social Work at the University of Washington in 1994 and have been a Licensed Independent Clinical Social Worker in Washington (Washington State License Number: LW 00005497) since July 2001 and in Arizona (AZBBHE License number: LCSW-20348) since April 2022.  

I have completed trainings, consultation, and practice in the evidence-based treatments of Cognitive-Behavior Therapy (CBT), as well as DBT.  I have supervised Social Work clinicians and students for many years. 

Confidentiality and Records

This office is compliant with the privacy rules of the Federal Health Insurance Portability and Accountability Act (HIPAA) of 1996. Please see my separate “Notice of Privacy Practices” for additional details and information regarding how I handle health care information collected about you in my practice. 

In most cases, communications between a client and their therapist will be held in strict confidence, unless the client provides their therapist with written permission to release information about their treatment, or in the case of the other specific exceptions, outlined below. 

Please note, I share office space with a group of independent mental health professionals. Although we share certain expenses and administrative functions, I am independent in providing clients with clinical services and am solely responsible for those services. My professional records are stored separately and no member of the group can access them without the client’s specific, prior, written permission. To provide each client with the best possible care, I sometimes consult with other mental health professionals regarding my cases. Information that could be used to identify the client or his/her family is not revealed during these consultations. The consultant is also legally bound to keep the information confidential.

While the written summary of exceptions to confidentiality, below, should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues, and as needed provide specific advice, but formal legal advice may be needed because the state and federal laws governing confidentiality are quite complex, and I am not an attorney. 

Please note that the confidentiality of email communication is not guaranteed to be secure, and I try to avoid this mode as much as possible. I will on occasion use email (with the client’s prior written permission) to arrange for appointment scheduling. Attached hereto is the Email Communication Agreement, which may be completed and signed in conjunction with this Disclosure and Policy Statement Acknowledgement and Consent. 

Exceptions to Confidentiality

There are some situations where I may be permitted or legally required to disclose information without either a client’s consent or authorization:  

• If a government agency is requesting the information for health oversight activities.  
• If a client files a complaint or lawsuit against me, I am permitted to disclose information as relevant for my defense.  
• If a client files a worker’s compensation claim, and such client’s psychotherapy is relevant to the injury involved in the claim. If properly requested, I must provide a copy of the client’s record to their employer and the Industrial Commission of Arizona: Labor Department, or other like government agency. 
• If I have reasonable suspicion that a child has suffered abuse or neglect, the law requires that I file a report with the appropriate government agency.  
• If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, the law requires that I file a report with the appropriate government agency.  
• If I have reason to believe a client or someone else is in imminent danger, I may be required to take protective action, including notifying potential victims, contacting the police, seeking hospitalization for the client, or contacting family members or others who can help provide for the client’s or other individual’s protection.  
• I am required to report myself or another healthcare provider in the event of a final determination of unprofessional conduct, a determination of risk to patient safety due to a mental or physical condition, or if I have actual knowledge of unprofessional conduct. If there are any questions or concerns about this requirement, please talk with me about them.

Social Media/Telecommunications

In order to maintain ethical boundaries, I do not accept “friend” or “follow” requests from current or former clients on their personal social networking sites (Facebook, Twitter, LinkedIn, Instagram, etc.), nor will I invite clients to participate or connect on any accounts related to me. Adding clients as “friends” or like connections on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship. I also do not communicate with, or contact clients, through such platforms. I ask that clients do not use these platforms and networking sites to contact me, as these sites are not secure and the messages may not be received or read timely. 

Similarly, I advise my clients to refrain from the use of email or texting to communicate with me, as these communications are not secure or encrypted and may not be read in a timely fashion. Generally speaking, texting and/or email should be used to arrange and/or modify appointments or other scheduling matters and not for any other use or discussion. If a client prefers to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so; however, while I will try to return messages in a timely manner, I cannot guarantee any immediate or timely response.   Furthermore, please ensure that you are emailing from an account accessible only by you (ie not a joint account or one for which others have passwords.)  Last, DO NOT EVER send photos over email or text. 

It is important to note, however, that engaging with me in this manner could compromise a client’s confidentiality. Neither texting nor e-mail is a substitute for therapy. If a session is needed, an appointment should be scheduled. Moreover, e-mail and text should not be used to communicate sensitive medical or mental health information, as again, it is not confidential or secure. All emails are retained in the logs of the 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 administrators of the ISP. It may also create the possibility that these exchanges become a part of the client’s legal medical record and will need to be documented and archived in such client’s medical chart. Be aware that any e-mail sent from a work account provides the employer the legal right to read such e-mail. Texting is not confidential or encrypted, and phones can be lost or stolen. 

It is imperative that no client communicates information of a sensitive nature over an email or text. All email, text, or other like telecommunication, which has not been clearly deemed secure or encrypted, shall be made at the clients own risk and I accept no responsibility or liability for any security or confidentiality issues which arise from a client utilizing such means of communication. Do not use email or text for emergencies. If it is an emergency, the client should call 911, the local emergency hotline, or go to the nearest emergency room.

Additionally, if you use location-based services on your mobile phone, I want to ensure all clients are aware of the privacy issues that may be related to using these services. If a client has GPS tracking enabled on your device, it impossible that others may conclude that such client is a therapy client due to the location.

Minors

If the client is under 18 years of age, and not emancipated, please be aware that the law may provide the minor client’s parents the right to examine the client’s treatment and/or other mental health records. 

One of the major purposes of therapy is to create a safe place for child(ren) to discuss any topic in a healthy manner. Many children (and more often adolescents) will not open up and reveal information if they are aware that the information will be disclosed. If appropriate, I may request the minor client’s privacy be honored during the course of therapy unless he or she discloses harmful situations at which time a parent would need to be involved in treatment to discuss how to keep the minor client safe.  Experience has shown that revealing therapy notes or the content of conversations can harm the trust relationship between therapist and minor clients, especially children. In many cases, if therapy is to be effective, the minor client must feel secure that specific confidences will not be revealed to anyone, including parents. 

However, if and when possible and/or appropriate under the circumstances, I may provide parents with certain information. If and as appropriate, I will only provide parents with general information about the work the minor client and I do together, unless required by law to provide more, or otherwise if I feel there is a high risk that the minor client will seriously harm themselves or someone else. In this case, I will notify the parents of my concern and provide them with all appropriate information and records. I may also provide parents with a summary of the treatment when it is complete. If and as reasonably possible and appropriate, prior to giving parents any information, I will discuss the matter with the minor client and do my best to handle any objections the minor client may have about what I am prepared to discuss and/or disclose.   

No matter how carefully this is explained, the minor client can invariably feel betrayed and may no longer choose to be in therapy with the individual who released the information. Sometimes this breach of trust may have an impact on other relationships as well such as the relationship between the parent(s) and the minor. At the outset of treatment, I will clarify limits to confidentiality between a minor and his or her legal guardian.

Divorced or separated parents often seek therapy for their children to help them deal with the stress and adjustment to the changes they are experiencing. It is my policy, with rare exceptions, that both parents of the child consent in writing to treatment and payment before the child is seen.  

It is essential that children have the contents of their therapy kept from becoming entangled in the adults’ legal issues. Therefore, you will be asked to sign an agreement below to protect your child’s confidentiality on court matters. 

Contacting Me/Emergencies

You may leave a confidential voicemail message for me at 425.588.9280, 24 hours a day. I check my messages regularly and will make every effort to return your call within 24 hours, though weekends/holidays may be longer.

If you cannot wait for me to return an urgent call, call the Crisis Hotline (Maricopa County) at (800) 631.1314 or (620) 222.9444, text HOME to the Crisis Text Line at 741-741, go to the nearest emergency room, or dial 911.

Appointments and Cancellations

Psychotherapy appointments are approximately 50 minutes long, but we may agree to have shorter or longer sessions, depending on the clinical issue. Similarly, for psychotherapy, I typically meet with clients once per week, but we may decide to schedule sessions more frequently, every other week or at longer intervals. Each appointment time is set-aside exclusively for the scheduled client, and I cannot fill that time slot without sufficient notice. To cancel an appointment, we ask the client to provide at least 24 hours notice. Failure to cancel at least 24 hours in advance may result in being charged and/or billed the full hourly fee ($150.00), though there may be exceptions granted if I agree that the appointment was unable to be kept due to circumstances beyond the client’s control.  In the event of a late arrival to an appointment, we ask that the client please call my office as soon as possible so that I know the client is coming and has not forgotten about the appointment. If a client arrives late for an appointment, that client will be billed the full fee for your session, regardless of whether we are able to conduct a full session or not. If sessions are routinely cancelled, even during the acceptable time frame, we will discuss an alternate fee cancellation policy.  Please note that insurance companies will not provide reimbursement for cancelled sessions. 

Professional Fees

Additional case management fees (which may or may not be covered by your insurance company) might include review of past records and phone call contacts with individuals such as teachers and physicians. My hourly therapy session fee is $175.00 (50 minute session) for individual therapy.  It is the responsibility of the client to confirm coverage with your insurance company.  While I do not bill insurance and am not paneled with any insurance carriers in Arizona, I will provide you with a super bill and CMS monthly so that you can submit for reimbursement.  Please note, I generally do not offer any sliding scale payment structures; however, in the event any such structure is offered, clients must be aware that they cannot utilize insurance for sliding scale payments. For the avoidance of doubt, any sliding scale fee structures/charges, if offered, are the sole responsibility of the client and cannot be submitted to insurance for coverage and/or reimbursement. 

In addition to weekly appointments, I charge $175.00 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals which a client has authorized, preparation of records or treatment summaries, and the time spent performing any other service a client may request of me. 

If any client becomes involved in legal proceedings that require my participation, such client will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300.00 per hour for preparation and attendance at any legal proceedings.   

Billing and Payments

Clients are expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. Moreover, as it relates to Billing and Payments, clients may be required to complete Credit Card Policy and Authorization. 

Please note, as a result of the No Surprises Act and Arizona law, there are certain client rights and protections against surprise medical bills. More specifically, “surprise billing” or “balance billing” is an unexpected balance bill resulting when a client can’t control who is involved in their care—like when there is an emergency or when someone schedules a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. In either case, clients may be protected against paying the surprise bill and are only responsible for paying their share of the cost (like the copayments, coinsurance, and deductible that would be paid if the provider or facility was in-network). Generally, the health plan must:

• Cover emergency services without requiring approval for services in advance (also known as “prior authorization”).
• Cover emergency services by out-of-network providers.
• Base what the insured owes the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount required to be paid for emergency services or out-of-network services toward the in-network deductible and out-of-pocket limit.

A client is never required to give up their protections from balance billing and are not required to get care out-of-network. Clients can choose a provider or facility in their plan’s network.  If a client believes they’ve been wrongly billed, they can contact the Arizona Department of Insurance and Financial Institutions at 1 (602) 364-3100. 

Delinquent Accounts

If a client’s account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, the costs associated will be included in the claim. 

In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with the client before taking any action.