Informed Consent

Informed Consent for Psychotherapy

General Information The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

In communication, persons sometimes prefer to communicate via text messaging or email. I do accept this form of communication, however, it is important for the client to understand that email is not a secure mode of communication. The correspondence is at risk of being intercepted, can be monitored by email providers, and human error could result in someone else receiving the email other than the intended therapist. It is also important to note that text messaging carries the same level of risk. Text messages can be intercepted, stored on a device and later read by others, read by phone providers, or sent to non-intended individuals. If the client chooses to correspond with me via text messaging or email, the messages and emails will be printed off and kept in the client’s file.

When working with minors, I will not share the content of sessions with parents/guardians, unless the content must be shared for safety reasons or if my therapist judgment warrants sharing content for the welfare and health of the minor. I will discuss progress and treatment plan in general terms with parents/guardians. Parents are encouraged to be a very active part of the counseling process; be prepared to be in session with your child at times and to have “homework assignments” for your family. Parents are required to remain at the HGCC office during their child’s (under age 16) appointments to be available for emergencies and to be involved in the therapeutic process.

It is possible that the client and counselor may cross paths in their personal lives. If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Professional Services

I am available for counseling appointments at select times throughout the week. The phone number to call to schedule appointments is 205-454-1897. I do not do phone consultations. If you have an emergency, you may obtain assistance by calling the Crisis Help Line at (205) 323-7777 or by going to your local hospital emergency room. I will be unable to respond to texts and emails in a timely manner, therefore do not text or email me when you are in a crisis and feeling suicidal, overwhelmed, or unsafe. Please call the crisis line or go to your nearest emergency room in these instances.

I am not a certified Custody Evaluator or an Expert Witness, as defined by the legal system. As a therapist, I am not permitted to make any judgments on custody. In the case that I would be subpoenaed to court or involved in any legal matter, the client will be charged a fee of $150 an hour (this includes note-taking, phone calls, writing case summaries, time to and from the court, etc). I do not testify unless required by a court order. Testimony under oath is $200 per hour.

In the case of my death, incapacitation, or termination of practice, my administrative director, Cami McKenzie, will assume responsibility for the management of my client’s therapy and records.

Credentials

All clinicians at Hope Grows Center for Counseling are licensed in the state of Alabama or master’s level counseling interns. Please contact the front office or consult with your therapist to obtain individual license numbers or to lodge complaints.

Practice Policies

PRACTICE POLICIES

Hope Grows Center for Counseling is committed to offering the highest quality of professional counseling services. Please let us know if there is anything we can do to increase your satisfaction with the quality of care you are receiving at any time by calling 205-454-1897 or emailing practice owner, Andrea Whitten, at andrea@hopegrowscenter.org.

INSURANCE

Insurance is an agreement between you and your insurance company as to how counseling will be paid for. We can assist you in contacting your insurance, providing you with a superbill for Out of Network reimbursement, and providing information on benefits to the best of our knowledge. These services are provided as a courtesy to our clients; however, it is your responsibility to contact your insurance company prior to your first appointment to confirm that your therapist is an approved provider for your insurance plan. You are responsible for payment of any fees your insurance plan does not cover including services that are not covered until your deductible is met. HGCC will make our best effort to process your insurance claims in a timely manner and to address any issues resulting in a denied claim. If a claim is denied three times, the client is responsible for payment of the full fee for services.

Most insurances want you to be diagnosed and usually dictate how many and what type of therapy you can have. We believe that that should be decided between you and your therapist. Therefore, we offer competitive rates if you choose to pay for your sessions yourself.

FEES

Our fee for all types of individual counseling services is $135 per clinical hour (55 min.). Initial intake interviews are $120 per clinical hour. Group counseling, when available, is $50 per session (typically 90 minutes). If you have any difficulty in paying this fee, you may apply for a sliding scale fee. Sliding scale fees are limited and based on income. Please contact the main office for more information about how to apply.

A session is typically based on a 55-minute hour. Cancellations should be made 24 hours in advance; otherwise, you will be billed a late cancellation fee of $50 to the card we have on file. Your appointment is considered a “no-show” if you fail to cancel your appointment and you do not come to your scheduled appointment. HGCC cannot reserve future appointments once a client no-shows for their appointment or cancels 3 consecutive appointments.

Payment is due at the time of your session. If you do not have your payment at the beginning of the session we will have to reschedule to another time when you can make the payment. You will owe for that session as well as the rescheduled one. If you accrue a balance of $100 or more on your account your counselor will be unable to schedule future counseling sessions until the balance is paid. If you would like to utilize insurance benefits to offset the cost of counseling services please discuss this with your counselor or the front office prior to your first appointment so that benefits may be determined in advance.

APPOINTMENTS & CANCELLATIONS

Please remember to cancel or reschedule 48 hours in advance. You will be responsible for a $50 late cancellation fee if the session is canceled less than 48 hours in advance. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time. If you are more than 15 minutes late, your appointment will be canceled and you will be responsible for the late cancellation fee of $50.

The standard meeting time for psychotherapy is 55 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 55-minute session need to be discussed with the therapist in order for time to be scheduled in advance.

A $10.00 service charge will be charged for any checks returned for any reason for special handling.

TELEPHONE ACCESSIBILITY

If you need to contact me between sessions, please leave a message at 205-454-1897. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions, and I currently do not offer phone sessions or consultations. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA & TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

MINORS

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

Good Faith Estimates

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provide a "Good Faith Estimate" about out-of-network care.

The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.

You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your provider have not previously talked about the change and you have not been given an updated good faith estimate.

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform individuals who are not enrolled in an insurance plan, have insurance coverage, enrolled in a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a "Good Faith Estimate" of expected charges.

Note: The PHSA and GFE does not currently apply to any clients who are using insurance benefits, including "out of network benefits" (i.e. submitting superbills to insurance for reimbursement).

Timeline requirements: "Practitioners are required to provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service.”

That estimate must be provided within specified timeframes:

If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling;
If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request.

A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.

Common Services Provided at Hope Grows Center for Counseling

90791- Initial Assessment (approx. 55 minutes)

90837- Individual Outpatient Therapy (approx. 55 minutes)

90834- Individual Outpatient Therapy (approx. 45 minutes)

90847- Family psychotherapy (conjoint psychotherapy) (with patient present) (approx 50 minutes)

Hope Grows recognizes that every client's therapy journey is unique.

How long you need to engage in Psychotherapy and how often you attend sessions will be influenced by many factors including:

Your schedule and life circumstances
Provider availability
Ongoing life challenges
The nature of your specific challenges and how you address them
Personal finances

You and your provider will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Where services will be delivered

We are a hybrid practice meaning we provide both in-person and telehealth services. Our address on record is at the top of this document.

* This is a list of providers you may see and their FULL fee. This estimate is based on IF you paid the provider(s) their FULL fee. This does not take into account any sliding scale fee that may be applied to your services at any time. We will not provide a new GFE for sliding scale discounts.

Andrea Whitten, LPC-S- $120 Initial Assessment, $135 per Follow-Up Session
Laura Beth Brown, LICSW- $120 Initial Assessment, $135 per Follow-Up Session
Katie Marshall, LICSW- $120 Initial Assessment, $135 per Follow-Up Session
Ria Gurganus, LMFT-A- $120 Initial Assessment, $135 per Follow-Up Session
Kenzie Wright, ALC- $120 Initial Assessment, $135 per Follow-Up Session
Chloe Barnette, Clinical Intern- $80 per session
Olivia Daidone, Clinical Intern- $80 per session

Client Diagnosis

At Hope Grows Center for Counseling, we provide a medical diagnosis for treatment planning and insurance reimbursement. It is within your rights to decline a diagnosis per state and federal guidelines.

This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis after an assessment has been completed. That will take place 1-5 sessions after beginning Psychotherapy or Nutrition therapy. If you choose to decline a formal diagnosis, we will not update this GFE.

The date of this GFE is the date that it is sent to you via the SimplePractice client portal.

The following is an example list of expected services, items, and charges for Hope Grows Center for Counseling for one year of weekly counseling services. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.

The estimated cost of Psychotherapy / Counseling if you had at least 1 initial assessment & used one 1 clinical hour of outpatient therapy every week for 51 weeks with the above-named provider(s):

$120 x 1= $120

$135 x 52= $7020

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for at least $400 more than this Good Faith Estimate, you have the right to dispute the bill. You may contact Hope Grows Center for Counseling to let us know the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, ask to negotiate the bill or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.