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Contact me using an encrypted form by clicking here. Please read the Informed Consent/Terms of Use and Notice of Privacy Policies, both listed below. This is NOT to be used in case of any crisis or emergency. The services offered do not include immediate crisis intervention - if you or someone you know is in any type of crisis situation, please call 911 or the National Suicide Prevention Lifeline 1-800-273-8255 and you will be directed to your local crisis intervention resource.
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**IMPORTANT NOTICE: This contact form is received at an encrypted account; please do not use an email address at which your confidentiality needs could be compromised by a reply. Use of this form constitutes acceptance of policies below and replies at the email address given.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES (NOTICE) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
I. Who Presents this Notice
This Notice describes the privacy practices of Emi M. Whittle, M.Ed., LPC, as your licensed professional counselor (“LPC”). This Notice applies to services furnished to you by the LPC involving the use or disclosure of your health information.
II. Privacy Obligations
LPC is required by law to maintain the privacy of your health information, referred to as “Protected Health Information” or “PHI,” and to provide you with this Notice of legal duties and privacy practices with respect to your PHI. When LPC uses or discloses your PHI, LPC is required to abide by the terms of this Notice.
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which are described in Section IV below, your written authorization must be obtained in order to use and/or disclose your PHI. However, LPC does not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations.
In general, your PHI may be used and disclosed to treat you, obtain payment for services provided to you and conduct “health care operations” as described below:
• Treatment. Your PHI may be used and disclosed to provide treatment and other services to you -- for example, to diagnose and treat your injury or illness. Your PHI also may be disclosed to other providers involved in your treatment.
• Payment. Your PHI may be used and disclosed to obtain payment for services provided to you -- for example, disclosures to obtain payment from Medicare, the Texas Medicaid program, your private health insurer, HMO, or other public or private third parties that arrange or pay the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.
• Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you. Your PHI also may be disclosed to your other health care providers, when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. In addition, your PHI may be shared with business associates who
perform treatment, payment and health care operations services on behalf of LPC.
C. Use or Disclosure for Additional Benefits. LPC may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
D. Disclosure to Relatives, Close Friends and Other Caregivers. Your PHI may be used or disclosed to family members, other relatives, close personal friends or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if (1) your agreement is obtained; (2) you are provided with the opportunity to object to the disclosure, and you do not object; or (3) it can be reasonably inferred that you do not object to the disclosure. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.
E. Public Health Activities. Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to federal or state authorities authorized by law to receive such reports; (3) to report information about products or services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may be at risk of spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work related illnesses and injuries or workplace medical surveillance.
F. Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
G. Health Oversight Activities. Your PHI may be disclosed to a state or federal health oversight agency that oversees the health care system, or another agency that is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
H. Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process, so long as the court order or process complies with applicable federal and Texas law.
I. Law Enforcement Officials. Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena, so long as the court order or subpoena complies with applicable federal and Texas law.
J. Decedents. Your PHI may be disclosed to a coroner, medical examiner or funeral director as authorized by law.
K. Health or Safety. Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to your, a person’s or the public’s health or safety.
L. Specialized Government Functions. Your PHI may be used or disclosed to federal officials for lawful intelligence, counterintelligence, and other national security activities. If you are a member of the armed forces or a foreign military authority, your PHI may be used or disclosed to the appropriate military authorities under certain circumstances.
M. Workers’ Compensation. Your PHI may be disclosed as authorized by, and to comply with, state law relating to workers' compensation or other similar programs.
N. Disaster Relief. Your PHI may be disclosed to the American Red Cross, or other agencies that provide similar services, in order to access any information necessary to perform its duties to provide biomedical services, disaster relief, disaster communication, or emergency leave verification services for military personnel.
O. As Required by Law. Your PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”).
B. Marketing. Your Authorization must be obtained for any use or disclosure of your PHI for marketing purposes, except if the communication: (i) is in the form of face-to-face communication made by LPC to the individual; (ii) is in the form of a promotional gift of nominal value provided by LPC to the individual; or (iii) is made to describe LPC’s services (or payment for such services) that are provided by LPC.
C. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and Texas law require special privacy protections for certain highly confidential information about you, including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about
mental health and/or mental retardation services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS or other sexually transmitted disease testing, diagnosis or treatment; (5) is about child abuse and neglect; or (6) is about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization must be obtained.
D. Reidentified Information. LPC shall not reidentify or attempt to reidentify you as the subject of any PHI without obtaining your consent or authorization if required under state or federal law.
E. Use and Disclosure of Information Upon Admission to a Psychiatric Unit or Chemical Dependency Treatment Center. Information regarding your care in LPC’s psychiatric unit or chemical dependency treatment center is subject to special protections under Texas and federal law. The terms of this Notice shall apply to your PHI unless otherwise described in this Section.
F. Psychiatric Treatment. As stated above, LPC may use and disclose your PHI to other health care professionals and personnel under the professionals’ direction for purposes of treatment and payment. On occasion, LPC may use or disclose your PHI to qualified personnel for certain health care operations, but to the extent possible, your personally identifiable information will be removed. LPC will not respond to inquiries about your treatment and will not disclose information revealing that you are a patient to unauthorized individuals, including family members, who call LPC to seek information, unless you have provided LPC with written consent. Your PHI will not be disclosed to family members or any other person seeking information about your care unless you provide written consent, or unless otherwise permissible
under federal or state law.
G. Alcohol and Drug Abuse Treatment. If you are a recipient of treatment for alcohol or drug abuse, your PHI related to such treatment is protected by federal confidentiality laws. Violations of these laws is a crime and may be reported to appropriate authorities. LPC will not disclose any PHI relating to your substance abuse treatment unless: (1) you provide written consent; (2) a court order requires disclosure of the PHI; (3)
medical personnel need the information to meet a medical emergency; (4) qualified personnel use the information for the purpose of conducting scientific research, management or financial audits, or program evaluation; or (5) it is necessary to report a crime or threat of a crime or to report abuse as required by law.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact LPC. You may also file written complaints with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. Upon request, LPC will provide you with the procedures for filing a complaint and correct address for the Secretary. LPC will not retaliate against you, if you file a complaint with the Secretary.
B. Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, LPC is not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from LPC.
C. Right to Receive Confidential Communications. You may request, and LPC will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, except to the extent that LPC has taken action in reliance upon it, by delivering a written revocation statement to LPC.
E. Right to Inspect and Copy Your Health Information. You may request access to, and copy, your medical record file and billing records maintained by LPC. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from LPC and submit the completed form to LPC. If you request copies, you will be charged in accordance with federal and state law. You also will be charged for postage costs, if you request that the copies be mailed to you.
F. Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from LPC and submit the completed form to LPC.
G. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request, provided such period does not exceed six years, and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged.
H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that LPC maintains, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted and you will be given an updated copy. You also may obtain any new notice by contacting LPC.
Complaints and Communications to the Federal Government: If you believe that your privacy rights have been violated, you have the rights to file a complaint with the federal government. You may write to:
Office for Civil Rights
U.S. Dept of Health & Human Services
150 S Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111
Email: [email protected]
You will not be penalized for filing a complaint with the federal government.
ACKNOWLEDGEMENT OF PRIVACY NOTICE
Client Name (please print): __________________________________________________________
I hereby acknowledge that I have received the Notice of Privacy Practices.
Signature __________________________________________________ Date __________________
Printed Name of Legal Guardian (if client is under age 18)
Legal Guardian’s Signature (if client is under age 18) and Date
NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES (NOTICE) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
I. Who Presents this Notice
This Notice describes the privacy practices of Emi M. Whittle, M.Ed., LPC, as your licensed professional counselor (“LPC”). This Notice applies to services furnished to you by the LPC involving the use or disclosure of your health information.
II. Privacy Obligations
LPC is required by law to maintain the privacy of your health information, referred to as “Protected Health Information” or “PHI,” and to provide you with this Notice of legal duties and privacy practices with respect to your PHI. When LPC uses or discloses your PHI, LPC is required to abide by the terms of this Notice.
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which are described in Section IV below, your written authorization must be obtained in order to use and/or disclose your PHI. However, LPC does not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations.
In general, your PHI may be used and disclosed to treat you, obtain payment for services provided to you and conduct “health care operations” as described below:
• Treatment. Your PHI may be used and disclosed to provide treatment and other services to you -- for example, to diagnose and treat your injury or illness. Your PHI also may be disclosed to other providers involved in your treatment.
• Payment. Your PHI may be used and disclosed to obtain payment for services provided to you -- for example, disclosures to obtain payment from Medicare, the Texas Medicaid program, your private health insurer, HMO, or other public or private third parties that arrange or pay the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.
• Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you. Your PHI also may be disclosed to your other health care providers, when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. In addition, your PHI may be shared with business associates who
perform treatment, payment and health care operations services on behalf of LPC.
C. Use or Disclosure for Additional Benefits. LPC may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
D. Disclosure to Relatives, Close Friends and Other Caregivers. Your PHI may be used or disclosed to family members, other relatives, close personal friends or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if (1) your agreement is obtained; (2) you are provided with the opportunity to object to the disclosure, and you do not object; or (3) it can be reasonably inferred that you do not object to the disclosure. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.
E. Public Health Activities. Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to federal or state authorities authorized by law to receive such reports; (3) to report information about products or services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may be at risk of spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work related illnesses and injuries or workplace medical surveillance.
F. Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
G. Health Oversight Activities. Your PHI may be disclosed to a state or federal health oversight agency that oversees the health care system, or another agency that is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
H. Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process, so long as the court order or process complies with applicable federal and Texas law.
I. Law Enforcement Officials. Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena, so long as the court order or subpoena complies with applicable federal and Texas law.
J. Decedents. Your PHI may be disclosed to a coroner, medical examiner or funeral director as authorized by law.
K. Health or Safety. Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to your, a person’s or the public’s health or safety.
L. Specialized Government Functions. Your PHI may be used or disclosed to federal officials for lawful intelligence, counterintelligence, and other national security activities. If you are a member of the armed forces or a foreign military authority, your PHI may be used or disclosed to the appropriate military authorities under certain circumstances.
M. Workers’ Compensation. Your PHI may be disclosed as authorized by, and to comply with, state law relating to workers' compensation or other similar programs.
N. Disaster Relief. Your PHI may be disclosed to the American Red Cross, or other agencies that provide similar services, in order to access any information necessary to perform its duties to provide biomedical services, disaster relief, disaster communication, or emergency leave verification services for military personnel.
O. As Required by Law. Your PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”).
B. Marketing. Your Authorization must be obtained for any use or disclosure of your PHI for marketing purposes, except if the communication: (i) is in the form of face-to-face communication made by LPC to the individual; (ii) is in the form of a promotional gift of nominal value provided by LPC to the individual; or (iii) is made to describe LPC’s services (or payment for such services) that are provided by LPC.
C. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and Texas law require special privacy protections for certain highly confidential information about you, including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about
mental health and/or mental retardation services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS or other sexually transmitted disease testing, diagnosis or treatment; (5) is about child abuse and neglect; or (6) is about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization must be obtained.
D. Reidentified Information. LPC shall not reidentify or attempt to reidentify you as the subject of any PHI without obtaining your consent or authorization if required under state or federal law.
E. Use and Disclosure of Information Upon Admission to a Psychiatric Unit or Chemical Dependency Treatment Center. Information regarding your care in LPC’s psychiatric unit or chemical dependency treatment center is subject to special protections under Texas and federal law. The terms of this Notice shall apply to your PHI unless otherwise described in this Section.
F. Psychiatric Treatment. As stated above, LPC may use and disclose your PHI to other health care professionals and personnel under the professionals’ direction for purposes of treatment and payment. On occasion, LPC may use or disclose your PHI to qualified personnel for certain health care operations, but to the extent possible, your personally identifiable information will be removed. LPC will not respond to inquiries about your treatment and will not disclose information revealing that you are a patient to unauthorized individuals, including family members, who call LPC to seek information, unless you have provided LPC with written consent. Your PHI will not be disclosed to family members or any other person seeking information about your care unless you provide written consent, or unless otherwise permissible
under federal or state law.
G. Alcohol and Drug Abuse Treatment. If you are a recipient of treatment for alcohol or drug abuse, your PHI related to such treatment is protected by federal confidentiality laws. Violations of these laws is a crime and may be reported to appropriate authorities. LPC will not disclose any PHI relating to your substance abuse treatment unless: (1) you provide written consent; (2) a court order requires disclosure of the PHI; (3)
medical personnel need the information to meet a medical emergency; (4) qualified personnel use the information for the purpose of conducting scientific research, management or financial audits, or program evaluation; or (5) it is necessary to report a crime or threat of a crime or to report abuse as required by law.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact LPC. You may also file written complaints with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. Upon request, LPC will provide you with the procedures for filing a complaint and correct address for the Secretary. LPC will not retaliate against you, if you file a complaint with the Secretary.
B. Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, LPC is not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from LPC.
C. Right to Receive Confidential Communications. You may request, and LPC will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, except to the extent that LPC has taken action in reliance upon it, by delivering a written revocation statement to LPC.
E. Right to Inspect and Copy Your Health Information. You may request access to, and copy, your medical record file and billing records maintained by LPC. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from LPC and submit the completed form to LPC. If you request copies, you will be charged in accordance with federal and state law. You also will be charged for postage costs, if you request that the copies be mailed to you.
F. Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from LPC and submit the completed form to LPC.
G. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request, provided such period does not exceed six years, and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged.
H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that LPC maintains, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted and you will be given an updated copy. You also may obtain any new notice by contacting LPC.
Complaints and Communications to the Federal Government: If you believe that your privacy rights have been violated, you have the rights to file a complaint with the federal government. You may write to:
Office for Civil Rights
U.S. Dept of Health & Human Services
150 S Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111
Email: [email protected]
You will not be penalized for filing a complaint with the federal government.
ACKNOWLEDGEMENT OF PRIVACY NOTICE
Client Name (please print): __________________________________________________________
I hereby acknowledge that I have received the Notice of Privacy Practices.
Signature __________________________________________________ Date __________________
Printed Name of Legal Guardian (if client is under age 18)
Legal Guardian’s Signature (if client is under age 18) and Date
Informed Consent and Terms of Use
Counseling Goals, Process, Methods, Nature of Services
The purpose of counseling is to help clients live fuller, healthier, happier lives (Client/Clients). The counselor (Counselor) will work with each client to establish goals meeting individual needs. The Client has the right to participate in ongoing counseling plans and the right to refuse any services or modality changes and to be advised of consequences of such refusal.
In general, the procedures for online/email counseling will follow similar processes as traditional counseling. You, the Client, will need to read and understand the Informed Consent and Privacy Policy, and return to Counselor with Client signature and date. Then we will discuss your needs, develop goals, and pursue the desired course of counseling. If your needs indicate other services requiring in-person contact, or those not provided in counseling, referrals will be made. Counseling can be brief or long-term, depending on the goals established. In general, the turn –around time for email inquiries will be within 2 business days, with client notification of any changes to that limit.
There is transfer plan in place – in the event of the incapacitation or death of the counselor, arrangements are in place for a qualified counselor to contact the client, and work with client to meet counseling needs and records requests.
Crisis services are not part of these services, and the client agrees to accept sole responsibility for using other means such as crisis hotlines, referrals, or 911 in the event of any urgent needs or threats of danger.
Counseling/counseling via email carries risks, benefits, and limitations. Participating in therapy can provide benefits such as possible reduction in stress, better coping skills, improved relationship skills, better overall mental health and well-being, and resolution of specific problems. Online/Email counseling avoids most transportation costs, and email exchanges avoids difficulties scheduling appointments. Further benefits can include flexibility, taking time to compose and reflect, and feeling less inhibited than in person. Working towards the benefits requires active effort, honesty, and openness, and willingness to change one’s thoughts and behaviors. However, changes on the client’s part may bring about feelings of stress or grief, and the resolution of some problems may cause other unexpected changes. There is no guarantee that therapy will yield positive or intended results. Techniques will be used to best treat the individual client and assist with attainment of goals. Counselor uses Cognitive Behavioral therapy, along with behavioral interventions, developmental theory, and educational techniques, drawing on education, experience, and training.
Other limits imposed by the use of online/email counseling can include factors such as lack of visual cues (for chat/email), and potential for misunderstandings, as well as potential technical security vulnerabilities. Client accepts responsibility for patient requests for clarification in communications. Client accepts the risk that any computer or service can be hacked, although reasonable measures can and will be taken to provide security, and will not hold Counselor liable for breaches nor failures. Client understands that there are other services available and other means of receiving assistance.
If there is any failure of technology the counselor will contact the client using the designated emergency contact. If there is any failure of technology on the client’s end, the client will accept full responsibility for securing alternative means of communication, and understands that after 30 days of no contact (unless due to planned interruption of service previously communicated and agreed upon) the client’s case will be closed, with no refunds allowed. Communication during technology interruptions may necessitate the use of code words or other means of verifying the client’s identity. If there is a failure of technology during chat or video/teleconference usage, wait 10 minutes and try again. If unable to reconnect, make another appointment.
Due to current laws, ethics, and insurance coverage, Counselor may only engage in a counseling relationship with clients who reside in Texas.
Counselors are limited to provision of services inside their scope of licensure. Assessments may be offered during the course of therapy to assist with evaluation, analyzing, and measuring progress. Counselors do not prescribe medications. Although it is usually recommended to consult with a medical services provider even when experiencing psychological symptoms, no information from the Counselor should be construed as qualified medical opinion. Counselors are prohibited from treating a client already under the care of a licensed mental health professional without being in direct contact with that professional, and must notify the other provider immediately upon discovery of a pre-existing treatment provider. Counselors are also prohibited from providing counseling to or engaging in any relationships with persons that may result in any dual relationships. Counselors may not provide services to family members, friends, education or business associates, nor anyone having a personal, familial, nor professional relationship with a client.
Confidentiality
Communications between the Counselor and Client are confidential, by law, with no disclosure except as allowed by law or authorized by the Client. Encrypted email/online services will be used, as well as password protection and encryption of data storage devices and locked files for paper records. However, the use of technology means that at any point in the electronic pathway, data may be unintentionally exposed. Counselor will make every effort to secure the Counselor’s technology, services, and equipment and records. Client must agree to take full responsibility for his/her end of the technology, services, and equipment. The Client accepts full personal responsibility for technological risk and will keep in mind the location and usage of equipment and services, and be sure to fully close out and log out of all emails and communications, and only store information in secure locations. Client will not hold Counselor liable for any electronic nor technological service failings. All information/content transmitted belongs to the Counselor and may NOT be re-transmitted in any form or fashion, or used for any other purposes.
Confidentiality may be breached by the counselor by law at any time for the following reasons: any suspected abuse, neglect or exploitation of children, disabled, or elderly persons; any concerned regarding abuse, neglect, illegal, unprofessional, or unethical conduct in an in-patient mental health facility, chemical dependency treatment facility, or hospital providing rehabilitation services; concerning sexual exploitation by a mental health services provider; or to inform medical or law enforcement personnel if there is any probability of physical injury by the client, to the client, or others, or for mental or emotional injury; or as ordered by a court of law. Additionally, if there is any indication of possible harm, Counselor will do everything possible within legal limits to prevent this including use of Emergency Contact information provided by Client. Information may be released with written authorization from the Client, however, requests may be denied if Counselor concludes this may be harmful in any way.
Due to the nature of counseling processes and in-depth personal disclosures of highly confidential information, Client agrees that should there be legal proceedings (including but not limited to divorce, custody disputes, injuries, lawsuits, etc.,) the Client, nor Client’s attorney, nor anyone acting on Client’s behalf will call on Counselor to testify in court or at any other proceeding, nor will any disclosure of psychotherapy records be requested.
By law, the Counselor must keep accurate records of the dates of counseling treatment, types of treatment, progress or case notes, intake assessment, treatment plan and billing. Counselor must keep records for 7 years, or 7 years beyond the age of 18 for minors. On the written request of a Client, Counselor shall provide a written explanation of types of treatment and charges for intervention previously made on a bill or statement.
Social Media
Due to the restrictions of confidentiality and prohibition against dual relationships, as well as for the best interest of Client’s privacy, Counselor cannot and will not knowingly engage Client in any social media environments in any manner or mode. This includes Facebook, Twitter, business reviews, and any other media. This is similar to protection of privacy in public – the Counselor will not knowingly engage in publicly acknowledging Client as having used Counselor’s services. Upon discovery of any potential dual relationship, Counselor will cease all contact immediately.
Consultation
Counselor may engage in consultation with other professionals, however, Client’s identifying information will not be disclosed for consultation purposes.
Fees
Current fees and services are listed on my website. Fees must be paid in full using arrangements available and Client is aware of confidentiality limits and potential risks of using payment services. Client agrees to accept risk and will not hold Counselor liable for any problems nor privacy issues resulting. Other arrangements can be made as needed, and if pre-arranged by Counselor, for example a money-order by mail. Client accepts responsibility for confidentiality limits and failures of technology of any arrangements outside of Counselor’s control.
Any missed appointments will not be refunded. Any email exchange not used will not be refunded, and if not used within 30 days, will not be refunded and services will be considered terminated. Appointments for online services may be rescheduled with 24 hours or more advanced notice.
At this time Counselor does not accept nor bill insurance. However, Counselor may be willing to assist Client in submitting a claim by providing an invoice showing fees paid to the client, using encrypted methods if electronically. Client also understands confidentiality limits when he/she chooses to submit this information to a third-party entities.
Counselor Credentials
Counselor, Emi M. Whittle, is currently licensed by the Texas State Board of Examiners of Professional Counselors, as a Licensed Professional Counselor, and Licensed Professional Counselor Supervisor. Counselor is also certified by the National Board for Certified Counselors, and holds a Masters of Education degree in Counseling.
Your signature or electronic signature attached to this document indicates that you have read and understood and agreed to the contents of Informed Consent/Terms of Use and the HIPAA Notice of Privacy Practices. You accept the risks and responsibilities outlined including full responsibility for payment in full for services. You agree to the terms of use as written, have received the opportunity to ask any questions and are satisfied with the answers, and do hereby consent to treatment, including using online therapy. You also acknowledge that you have received information regarding other resources and accept responsibility for using crisis intervention and other services not provided by Counselor or when referred by Counselor and will not hold Counselor liable in any way for services not provided by Counselor.
Client Printed Name: _____________________________________________
___________________________________ ____________________
Signature Date
Counselor: Emi M. Whittle, LPC PLLC
700 Lavaca St, Ste 1401
Austin, TX 78701
Texas State Board of Examiners of Professional Counselors Complaint Process
http://www.dshs.state.tx.us/counselor/lpc_complaint.shtm
An individual who wishes to file a complaint against a Licensed Professional Counselor may write to:
Complaints Management and Investigative Section
P.O. Box 141369
Austin, Texas 78714-1369
or call 1-800-942-5540 to request the appropriate form or obtain more information. This number is for complaints only. Please direct routine calls and correspondence to the phone number and address on the "Contact Us" page.