This form provides you with information that is in addition to that detailed in the Notice of Privacy Practices.

1. Counseling is a collaborative process between you and a counselor to work on areas of dissatisfaction in your life and assist you with life goals. For counseling to be most effective, it is important that you take an active role in the process. Counseling activities are governed by the Texas State Board of Examiners for Professional Counselors for LPC’s and the Texas State Board of Social Work Examiners for LMSW’s . I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress. I do not provide custody evaluation recommendation, nor medication or prescription recommendation, nor legal advice, as these activities do not fall within my scope of practice.
2. Time Parameters: Individual appointments are scheduled for 45-minute segments. Being late for an appointment by 15 minutes or more may require that you reschedule.
3. Confidentiality: As a Licensed Professional Counselor or Licensed Social Worker in the State of Texas, I am bound by the Texas Administrative Code, Chapter 681 and the Health and Safety Code, Chapter 611. In accordance with these rules, information obtained in the counseling session or in written form will not be disclosed to any outside person(s) or agency without your written permission except when such disclosure is necessary to “protect you or someone else from imminent harm” or is otherwise legally required and/or allowed by law, such as abuse or neglect of a child under 18, elder, or disabled person. This notification may include notifying the victim, notifying the police, or seeking appropriate hospitalization. I may also be required to provide information to the court if provided a court order. If a client files a worker’s compensation claim or disability claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. If any of the above situations arise, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. If you are under 18, your parents or legal guardian(s) may have access to your records and may authorize release to other parties. If I run into you outside of the counseling office, I will protect your confidentiality and wait for you to acknowledge me should you choose to do so.
4. Risks: In counseling, major life decisions are sometimes made, including decisions involving separation within families, development of other types of relationships, changing employment settings and changing lifestyles. The decisions are a legitimate outcome of the counseling experience as a result of an individual’s calling into question many of their beliefs and values. Furthermore, symptoms may be intensified and the emotional experience may be too intense to deal with at this time. I will be available to discuss any of your assumptions or possible negative side effects in our work together. There is no guarantee of what you will experience in counseling.
5. Cancellation: If you find it necessary to cancel an appointment, please contact the receptionist at 956-369-7997 or your counselor at least 24 business hours in advance. Cancellations with less than 24 hours advance notice will be charged a $50 no-show fee. The provider may also terminate counseling in the event the client has missed 3 appointments without calling to cancel 24 hours prior to the scheduled appointment.
6. Emergencies: If an emergency situation for which you feel immediate attention is necessary, please contact emergency services (911) immediately, the 24-hour MHMRA Helpline, 800-289–7000, who will determine the need to go to the Psychiatric Emergency Service located at 2102 W. Trenton Rd, Edinburg, Texas (24-7 walk-ins), or go to your nearest hospital emergency room. Keep in mind that while I may be in the office I do not answer the phone while in session with a client. If I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can, within the limits of the law, to prevent you from injuring yourself others and to ensure that you receive the proper medical care. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of injury to self or others. If I will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact, if necessary. Please do not use e-mail and faxes for emergencies.
7. Fees and Payment will be collected at the time of service; cash, check, Visa, MC, AMEX or Discover are acceptable forms of payment. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc… will be charged at the standard rate in the payment contract for services, unless indicated and agreed upon otherwise. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. If requested, I will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. You must be aware that not all issues/problems dealt with in counseling are reimbursed by insurance companies and filing may require the release of confidential information such as mental health diagnosis, which could be utilized in future insurance decisions. It is your responsibility to verify the specifics of your coverage and determine if pre- authorization is required.
8. Health Insurance & Confidentiality of Records: If you want your EAP or insurance to pay for part of your treatment, I must be able to discuss your diagnosis and treatment with their representative if they contact me for additional information. I have no control or knowledge over what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk of confidentiality or privacy.
9. Consultation, Supervision: Information about you may be discussed in confidence, without revealing your identity, with other counseling professionals for the purpose of consultation and providing you the best possible service. If you are working with a Licensed Professional Counselor Intern or Licensed Clinical Social Worker Intern, your therapist is required to discuss your case on a regularly scheduled basis with his/her Supervisor. The Supervisor is also required to maintain confidentiality.
10. Electronic Transmission: I cannot ensure the confidentiality of any form of communication through electronic media. You are advised that any email sent to me via a computer in a work-place environment is legally accessible by an employer. I do not always check email daily.
11. Records: I am required by law to maintain records of each time we meet or talk on the phone. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. A judge can subpoena your records for a variety of reasons, and if this happens, I must comply. I can be called to testify about the contents of the records and I must comply. Also, in order to file for insurance reimbursement, I have to assign you a diagnosis. If you have any questions about this, please let me know. I will certainly share any information with you that I provide to an insurance provider. If records are requested for any purpose, my policy is to provide an appropriate summary as records can be misinterpreted.

12. CHILDREN SEEKING SERVICES

If you are a parent or guardian who is consenting to treatment for a minor, by signing this Agreement you affirm that you are the parent or legal guardian of the child, that you have the legal right to consent to psychological treatment for the child, and that there has not been a divorce decree or any other court order that limits your ability to consent to the child’s treatment.

If the child’s parents are divorced or never married, it is STCA’s policy to require BOTH parents to consent to treatment, in compliance with any divorce decree or court order that may be in place. We will also require a copy of the divorce decree or court order prior to providing any services to the child.

We will not schedule an appointment for your child until all documentation has been received.

Children at Sessions

STCA is sensitive to the needs of families; however, we do not have the capacity to provide childcare while you are in your session. We do not allow children in counseling sessions unless they are the client. Children may not be left unattended in the waiting area.

12. SOUTH TEXAS COUNSELING AGENCY does not want to be involved in litigation. STCA does not provide court- related services, including, but not limited to: meeting with attorneys, depositions (in person or recorded), providing testimony (in person or recorded), and creating reports for court or court appearances. When engaged in court-related activities, your therapist must clear their schedule and not see other clients. This is unfair to other clients and seriously compromises our ability to attend to their care and treatment.

We do not want to be bound by subpoenas, interact with lawyers, or be legally compelled to disclose your confidential information in court. The nature of the therapeutic process often involves making a full disclosure regarding matters you have discussed in therapy, which may be extremely private, upsetting, or embarrassing. If you become involved in any legal issue while you are a STCA client, including but not limited to: divorce proceedings, custody disputes, or personal injury lawsuits, you agree that neither you nor your attorney(s) nor anyone acting on your behalf will subpoena records from this office or subpoena any therapist to testify in court, at a deposition, or in any legal proceeding.

If you involve South Texas Counseling Agency or your therapist in litigation or if you or your attorney(s) subpoenas STCA to provide your records, provide testimony (in person or recorded), or give a deposition (in person or recoded) in violation of this agreement, STCA will comply with lawfully issued subpoenas. However, the following policies will be applied:

• You agree to pay for all time expended in complying with lawfully issued subpoenas, including but not limited to preparation, record review, transportation charges (door to door), waiting time, and time spent testifying in court or deposition regardless of which party issues the subpoena or compels STCA to comply.
• If we are required to testify in court or give a deposition, we will charge a fee of $1200 per half day, $2400 per day with a minimum fee of $1200 to be charged, per STCA representative compelled to appear.
• We charge$300/hour for all other litigation-related activities, suchas; preparation, records review, giving a deposition, waiting to testify at the courthouse/deposition location, travel time (door-to-door) to the courthouse/deposition location and back, consultation with the client’s attorney, preparation of the records, in addition to the above-stated appearance fee.
• If we are required to testify in court or give a deposition outside of Hidalgo County, we will charge a fee of $1500 per half day, $3000 per day with a minimum fee of $1200 to be charged, per STCA representative compelled to appear.
• You also agree by your signature below to execute and sign a Credit Card Authorization and provide a valid credit card to ensure payment for the time we spend on your litigation. We will require that you provide your credit card information in advance. Charges that are not valid or honored by your credit card company will be payable by cash or money order within 10 business days or the bill will be sent to collections.
• Payment for court-related services is non-refundable will be charged to your card at the

time these services are provided.

No personal checks will be accepted for court-related services.

13. Termination: If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, will provide him or her with the essential information needed. You have the right to terminate therapy at any time.

I have read, understood, agree, and consent to the above conditions of service stated. I have also received the notice of privacy practices on this date and have had the opportunity to ask questions about and understand these policies.

14. Interactions Outside the Office

If a staff member from STCA, either your therapist or any other staff member, happens to encounter you outside of the professional setting we will not address you unless you address us first. This is for the protection of your privacy and to respect professional boundaries. We are happy to return a friendly greeting but will wait for you to take the initiative. Even if you initiate the interaction, we will not reference that you are or ever have been a client.

15. Contacting Your Therapist

Other than session attendance, the only way your therapist should be contacted is by the office phone. Our office hours vary, and we are often not immediately available by telephone. We return calls within 12-24 hours during regular business hours.

In order to have your phone call returned you must leave your name and your phone number on the voice mail. Our phones do not record caller ID numbers and do not show us a record of who has called. You must leave a message if you wish us to return your calls.

If your therapist conducts a therapy session by phone private pay fees apply. Be sure to talk to your therapist beforehand.

If you experience a mental health emergency and your therapist is not available by telephone, you should utilize the emergency contacts numbers and agencies listed under: Emergency Situations.

16. Use of Electronic Communications:

Email and texting are for scheduling only. We do not use email/texting with clients regarding clinical matters as we cannot guarantee that it is confidential and secure. If you need to discuss a clinical matter between sessions, please call your therapist at their office telephone number and make appropriate arrangements.

17. Social Media

We do not engage in communication or relationships via social media with clients. This is for the protection of our agency, the protection of your confidentiality, and the protection of the therapeutic relationship. This includes not only STCA Counseling Center, but your therapist as well. Neither STCA or your therapist will communicate with you through social media,

post anything about or with current or former clients through social media or accept “friend” requests from current or former clients. STCA and our therapists respect your confidentiality and your privacy and are bound by applicable state and federal laws and licensing requirements. Please treat our therapists with the same respect. If you see a post on social media made by STCA about an upcoming event, fundraiser, or other public information you are free to share it. Please do not expect a conversation or interaction with STCA or any of our therapists through any social media site or app.

18. No Recording Sessions Policy

All meetings, communication, phone calls, appointments, or sessions are not recordable. Recording sessions are against policy resulting in termination and are furthermore inadmissible.

19. Couples Therapy Policy

If you are here to work on a relationship problem, it’s important for you to understand what we believe about relationships and marriage.

First of all, we do not have preconceived notions about whether you should stay together or part ways. We believe it is important to explore such questions openly, honestly, and thoroughly. Once your goals are established, we will work diligently to support you in achieving them, whatever they may be. Second, you are entrusting me to use my professional judgment as it relates to individual confidences.

By signing this form, you are acknowledging that anything you communicate to me individually by phone, email, or any other means may be important to bring up and work on in a couple therapy session, and I reserve the right (but not the obligation) to do so.

19. Complaints

We hope that you will discuss any dissatisfaction with your therapist’s services directly with your therapist. All STCA staff are committed to trying to resolve your concerns. Any staff member can tell you how to file a grievance. The contact information for the State boards that license all STCA therapists is posted in the waiting area. If STCA staff members are unable to resolve your concerns, you may speak with STCA Counseling Center’s Clinical Director.

PAYMENT CONTRACT FOR SERVICES

Fees: If STCA is billing your insurance, you are required to pay your copay at the time the service is provided. If your policy has an unmet deductible or denies payment based on lack of medical necessity, you will need to pay our full fee for service or talk to your therapist about payment.

If you fail to notify us when your insurance becomes inactive, you may accrue significant fees. If you have insurance and do not tell us until after the effective date has begun, then you will owe us the difference between the fee you are paying and the co-pay (if the co-pay is higher). If the co-pay is lower, we will credit the difference to your account. You are responsible for knowing what mental health services your insurance policy covers. If you have questions about your coverage, call your plan administrator.

If, after beginning therapy, your current fee creates a financial hardship, you must discuss this with your therapist before your next session. You may be eligible for a reduced fee, but this must be arranged prior to your next session. We do not adjust fees already accrued.

FEDERAL TRUTH IN LENDING DISCLOSURE STATEMENT FOR PROFESSIONAL SERVICES

Part One Fees for Professional Services

 

Part Two Charges:

Clients are responsible for full payment at the time of services. Services will be terminated if timely payment is not made as agreed to by this consent.

I authorize the counselor or office representative to communicate with my insurance company about the coverage for my dependent or myself.  I authorize the release of billing information to my insurance company or Medicaid concerning provided services and to forward statement of charges to my home.

I understand that there are fees for professional services provided and that these fees have been discussed with me.  I accept responsibility for the charges incurred including the “V” codes or services that may be denied by my insurance company.  Payment is due at time of services unless arrangements have been made.

I understand and accept that if I fail to pay for the services rendered by South Texas Counseling, that my name and information will be submitted to the Credit Bureau. I further understand and accept that if I issue a check that is returned for insufficient funds, that I will be charged an administrative fee and reported to the legal authorities if necessary.

My signature below indicates that I have read and understood this contract and that any questions I had about the statements were answered to my satisfaction.  I have also read and had the opportunity to discuss the above statements, which I have initialed.

I further agree for my counselor or her office staff to communicate with me via telephone, email, text or fax to remind me of my counseling appointments or cancellations.

Part Three Minors:

The adult accompanying a minor (or guardian of the minor) is responsible for payments for the child at the time of service. Unaccompanied minors will be denied non-emergency service unless charges have been preauthorized to an approved credit plan, charge card, or payment at the time of service.

Thank you for understanding the financial policy and payment contract. Please let us know if you have any questions or concerns.

I (we) have read, understand, and agree with the provisions of the Financial Policy and

Payment Contract for Services.

NOTICE OF PRIVACY PRACTICES – SOUTH TEXAS COUNSELING AGENCY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice is effective as of March 29, 2005.

I am required by applicable federal and state law to maintain the privacy of your health information and inform you of my privacy practices, legal obligations, and your rights concerning your health information. I must follow the privacy practices that are described in this Notice (which may be amended from time to time).

I am required to abide by the terms of the Notice of Privacy Practices that is most current. I reserve the right to change the terms of the Notice at any time. Any changes will be effective for all protected health information that I maintain. The revised Notice will be posted in the waiting room. You may request a copy of the revised Notice at any time.

I will answer your questions about my privacy practices and do ensure that I will comply with applicable laws and regulations. I will also take your complaints and can give you information about how to file a complaint.

I. USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION THAT MAY BE MADE TO CARRY OUT HEALTHCARE OPERATIONS.

I may use and disclose limited information from your record without your written authorization, excluding Counseling Notes as described in Section IV, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

Treatment: I may use and disclose limited information in order to provide treatment to you. For example, I may use information to diagnose and provide counseling service to you. In addition, I may disclose information to other health care providers involved in your treatment.

Payment: I may use or disclose limited information from your record to obtain payment for the services you receive. For example, I may submit your diagnosis with a health insurance claim in order to demonstrate to the insurer that the service should be covered.

Health Care Operations: I may use and disclose information from your record to allow health care operations including quality improvement activities, training programs, reviewing records to see how care can be improved, accreditation, certification, licensing or credentialing activities. For example, I may use information in your record to train another counselor.

II. YOUR INDIVIDUAL RIGHTS

Right to Inspect and Copy. You may request access to the information in your record maintained by me in order to inspect and make a copy of it. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested.

Right to Request Restrictions. You may ask to restrict the use and disclosure of certain information in your record that otherwise would be allowed for treatment or payment. You must request any such restriction in writing. I am not required to agree to any such restriction you may request.

Right to Accounting of Disclosures. You have the right to request an accounting of any disclosures made by me after March 29, 2005.

Right to Request Amendment: If you believe information in your record is inaccurate or incomplete, you may request amendment of the information. You must submit sufficient information to support your request for amendment. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.

Right to Obtain Notice. You have a right to obtain a paper copy of this Notice upon request.

Right to Complain. You have the right to complain to us about our privacy. You have the right to complain to the Secretary of the Department of Health and

Human Services about our privacy practices. You will not face retaliation from us for making complaints.

Except as described in this Notice, I may not make any use or disclosure of information from your record unless you give me your written authorization. You may revoke an authorization in writing at any time, but this will not affect any use or disclosure made by us before the revocation. In addition, if the authorization was obtained as a condition of obtaining insurance coverage, the insurer may have the right to contest the policy or a claim under the policy even if you revoke the authorization.

III. USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION THAT I AM REQUIRED TO MAKE WITHOUT YOUR PERMISSION.

Communications between a counselor and client are privileged and may not be disclosed without your permission, except as required by law. For example, counselors must report suspected abuse/neglect of a child, elder, or disabled person. I may have to breach confidentiality if you appear to post an imminent danger to yourself or others, in order to reduce the likelihood of harm to you or others. Also, I must disclose information to the Department of Health and Human Services, if requested, to prove that I am complying with regulations that safeguard your health information.

I may disclose information from your record if ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, I may disclose information in response to a subpoena or other legal process, even without a court order.

You have a right to receive confidential communications from me. For example, if you want to receive bills and other information at an alternative address, please notify me. I may contact you to provide information or appointment reminders as a courtesy. Please notify me if I am not to leave a telephone message or use electronic communication. You are responsible for remembering your appointment, whether or not you receive a reminder.

I may contact you with information about treatment alternatives or other health-related benefits or services that may be of interest to you.

IV. USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Counseling Notes: Notes recorded by your counselor documenting the contents of a counseling session with you (“Counseling Notes”) will be used only by your

clinician and will not otherwise be used or disclosed without your written authorization.

Marketing Communications: I will not use your health information for marketing communications without your written authorization.

Other Uses and Disclosures: Uses and disclosures other than those described in Section I & III above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send information to a school, or to your attorney. You may revoke any such authorization at any time.

Consent for the Use or Disclosure of Health Information for Treatment, Payment, or Health Care Operations

In our Notice of Privacy Practices, we provide you information about how SOUTH TEXAS COUNSELING AGENCY can use or disclose your mental health and medical information. As described in our Notice of Privacy Practices, we request your consent for any use or disclosure of mental health and medical information necessary to carry out treatment, payment or health care operations. You have a right to review our Notice of Privacy Practices before signing this Consent form.

By signing this Consent form, you: 1) Acknowledge that a copy of the Notice of Privacy Practices has been provided to you; and 2) Consent to our use and disclosure of your health information for treatment, payment or health care operations, as described in the Notice of Privacy Practices.

You have the right to revoke this Consent in writing at any time, except where we have already used or disclosed your health information in reliance upon this Consent.