Life Online Counseling, LLC

Terms of Service

CONSENT TO CONSULTATION / TREATMENT

The following is an agreement to enter into a CONSULTATION / TREATMENT PROCESS. The purpose of this process is:

  1. To affirm the fit between Life Online Counseling and you as the client; and

  2. To determine an appropriate therapist for you.

During the consultation process, both you and your therapist can mutually agree to decide to move into psychotherapy treatment together.

Life Online Counseling is a counseling center. As such, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of your personal health information for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of your first session.

CONSULTATION PROCESS: Your first sessions are a consultation which includes:

  • Completing necessary paperwork;

  • Meeting with a therapist; and

  • Possibly taking a Personality Assessment Inventory (PAI).

If it appears that we can provide you with services helpful to your concerns, you will be assigned a therapist. However, it is sometimes necessary to refer you to another clinician. If this occurs, your file will automatically be transferred to your regular ongoing therapist with your written permission.

APPOINTMENTS: Your appointment time is reserved for you. It is your responsibility to notify your therapist or office administrator at least 48 hours in advance if you are unable to attend. Cancellations of appointments less than 48 hours in advance and “no shows” are subject to the full fee for the appointment time.

LIMITS ON CONFIDENTIALITY: There are some situations in which a therapist is legally obligated to take actions that the therapist believes are necessary to attempt to protect client or others from harm, and the therapist may be required to reveal limited information about a client’s treatment.

CHILD ABUSE: If a therapist has knowledge of or reasonably suspects a child under 18 has been the victim of child abuse or neglect, the law requires that the therapist file a report with the appropriate government agency. This can include when a therapist reasonably suspects that mental suffering has been inflicted upon a child or that his/her emotional wellbeing is endangered in any other way. It can also include some sexual activity i.e. oral sex among minors under certain conditions. If you have any questions please clarify this with your therapist. Once such a report is filed, the therapist may be required to provide additional information.

DANGER TO SELF: If a therapist has reasonable cause to believe that the client is in such mental or emotional condition as to be dangerous to oneself, the therapist may be obligated to take protective action, including seeking hospitalization or contacting family members or others who can help provide protection.

THREAT OF VIOLENCE TO OTHERS: If a client communicates a serious threat of physical violence against an identifiable victim, the therapist must take protective actions, including notifying the potential victim and contacting the police. The therapist may also seek hospitalization of the client or contact others who can assist in protecting the victim.

ELDER/DEPENDENT ADULT ABUSE: If a therapist observes or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he/she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that the therapist report to the appropriate government agency. Once such a report is filed, the therapist may be required to provide additional information. If such a situation arises, your therapist will limit disclosures to what is necessary.

PRIVACY: The law protects the privacy of all communications between a client and a therapist. In most situations, your therapist can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by state law and/or HIPAA. However, there are some situations where your therapist is permitted or required to disclose information without either your consent or authorization:

CONSULTATION: Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, he/she will make every effort to avoid revealing the identity of clients. The other professionals are also legally bound to keep the information confidential. Your therapist may not discuss these consultations with you unless he/she feels that it is important to your work together. All consultations are noted in your Clinical Record.

ADMINISTRATIVE STAFF: Your therapist may need to share protected information with administrative staff for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All our mental health professionals are bound by the same rules of confidentiality, and all staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.

COLLECTION: Disclosures required to collect overdue fees are discussed elsewhere in this Agreement. If you do not pay your fee, we are legally permitted to contact a collection agency.

COURT PROCEEDINGS: If you are involved in a court proceedings and a request is made for information about the professional services provided to you, such information is protected by therapist-patient privilege law, and will be provided only with your (or your legally-appointed representative’s) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) and has stated valid legal grounds for obtaining PHI and your therapist does not have grounds for objecting under state law (or you have instructed him or her not to object). If you are involved in, or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information.

GOVERNMENT AGENCIES: If a government agency is requesting the information for health oversight activities pursuant to their legal authority, your therapist may be required to provide it for them.

LAWSUITS: If a client files a complaint or lawsuit against his/her therapist, relevant information may be disclosed regarding that client, without client consent in order for the therapist to defend themselves.

WORKER’S COMPENSATION: If a client files a worker’s compensation claim, the therapist must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer.

NON-EMANCIPATED MINOR CLIENTS under 18 years of age can consent to psychological services subject to the involvement of their parents or guardian. The following statutes may by applicable in this situation:

  • Therapist must determine whether or not parental involvement will be inappropriate for the minor.

  • Minors over 12 years of age may participate intelligently in therapy services when the minor client either would present a danger of serious physical or mental harm to him/herself or others, or is the alleged victim of incest or child abuse.

  • Minors over 12 years of age may independently consent to alcohol and drug treatment.

  • Parents or guardians of clients under 18 years of age who are not emancipated may be allowed to examine their child’s treatment records unless the therapist determines that access would have a detrimental effect on the professional relationship with the client, or to his/her physical safety or psychological well-being.

  • Minors over 12 years of age will be required to sign a consent to treatment and the therapist may provide parents or guardians with only general information about the progress of the treatment, a summary of treatment, and the client’s attendance at scheduled sessions. Any other communication will require the minor’s authorization, unless the therapist believes that the child is in danger or is a danger to someone else, in which case, the therapist will notify the parents or guardians of such concerns. Before giving parents any information, the therapist will discuss the matter with the minor, if possible, and try to handle any of the therapist’s objectives.

TERMINATION OF THERAPY: Your therapist will provide counsel for you regarding termination, but you must make the ultimate decision about continuing care. It is to the client’s advantage that a decision to end therapy will be discussed candidly and thoroughly with the therapist in advance of leaving.

PAYMENT & FEES: You are expected to pay for services at the time they are rendered unless other arrangements have been made. Services are rendered and charged to the client, not to the insurance company. Your therapist will provide you with a SuperBill to submit to your insurance company for reimbursement. You may also incur charges for phone calls lasting more than 15 minutes, letters and testing fees. There is a $20.00 charge for returned checks.

I, the client, agree to be responsible for the payment of $75.00 per session (50 minutes) which is payable at the time of the session. I understand that I am responsible for payment, even though I may be reimbursed by my insurance company.

Please feel free to discuss any concerns you may have with your therapist as they arise. This form is a HIPAA document and complies with both state and federal requirements.

INFORMED CONSENT TO TELEHEALTH

Telehealth allows my therapist to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. I hereby consent to participate in psychotherapy via telephone or the internet (hereinafter referred to as Telehealth) with my therapist.

I understand I have the following rights under this agreement:

I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during my therapy, therefore, is generally confidential.

There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent.

I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to Telehealth communications by providing written notification to Life Online Counseling.

HIPAA POLICY

NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Disclosures for Treatment, Payment and Health Care Operations

A Life Online Counseling therapist may use or disclose your protected health information (PHI), for certain treatment, payment, and health care operations purposes without your authorization. In certain circumstances, he/she can only do so when the person or business requesting your PHI provides a written request that includes certain promises regarding protecting the confidentiality of your PHI. To help clarify these terms, here are some definitions:

  • “PHI” refers to information in your health record that could identify you.

  • “Treatment” is when a therapist or another healthcare provider diagnoses or treats you. An example of treatment

    would be when a therapist consults with another health care provider, such as your family physician or another

    psychologist, regarding your treatment.

  • “Payment” is when a therapist obtains reimbursement for your healthcare.

  • “Use” applies only to activities within Life Online Counseling such as sharing, employing, applying, utilizing,

    examining, and analyzing information that identifies you.

  • “Disclosure” applies to activities outside of Life Online Counseling such as releasing, transferring, or providing access

    to information about you to other parties.

  • “Authorization” means written permission for specific uses or disclosures.

II. Uses and Disclosures Requiring Authorization

A therapist may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment and payment operations, your therapist will obtain an authorization from you before releasing this information. You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time; however, the revocation or modification is not effective until we receive it.

III. Uses and Disclosures with Neither Consent nor Authorization

A therapist may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: Whenever a therapist, in his/her professional capacity, has knowledge of or observe a child he/she knows or reasonably suspects has been the victim of child abuse or neglect, he/she must immediately report suchto a police department, sheriff’s department, county probation department, or county welfare department. Also, if a therapist has knowledge of or reasonably suspects that mental suffering has been inflicted upon a child or

    that his/her emotional well-being is endangered in any other way, the therapist may report such to above.

  • Adult and Domestic Abuse: If a therapist, in his/her professional capacity, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult; if a therapist is told by an elder or dependent adult that he/she has experienced these; or if a therapist reasonably suspects such, the therapist must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency.

A therapist is not required to report such an incident if the therapist has been told by an elder or dependent adult that he/she has experienced behavior constituting physical abuse, abandonment, abduction, isolation, financial abuse or neglect and the therapist is not aware of any independent evidence that corroborates the statement that the abuse has occurred; (a) the elder or dependent adult has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservator ship because of a mental illness or dementia; and (b) in the exercise of clinical judgment, the therapist reasonably believes that the abuse did not occur.

  • Health Oversight: If a complaint is filed against a therapist with the California Board of Psychology or the California Board of Behavioral Science, the Board has the authority to subpoena confidential mental health information from the therapist relevant to that complaint.

  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that I have provided you, I must not release your information without (a) your written authorization or the authorization of your attorney or personal representative; (b) a court order; or (c) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court- ordered. I will inform you in advance if this is the case.

  • Serious Threat to Health or Safety: If you communicate to me a serious threat of physical violence against an identifiable victim, I must make reasonable efforts to communicate that information to the potential victim and the police. If I have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, I may release relevant information as necessary to prevent the threatened danger.

  • Worker’s Compensation: If you file a worker's compensation claim, I must furnish a report to your employer, incorporating my findings about your injury and treatment, within five working days from the date of the your initial examination, and at subsequent intervals as may be required by the administrator of the Worker’sCompensation Commission in order to determine your eligibility for worker’s compensation.

IV.Patient's Rights and Psychologist's Duties

Client’s Rights:

  • Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

  • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

  • Right to Inspect and Copy. You have the right to inspect or obtain a copy of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request/denial process.

  • Right to Amend. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

  • Right to an Accounting. You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization. On your request, I will discuss with you the details of the accounting process.

  • Right to a Paper Copy. You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Therapist’s Duties:

  • I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

  • I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

V. Complaints

If you are concerned that a therapist has violated your privacy rights, or you disagree with a decision he/she has made about access to your records, you may contact the Office Administrator at (949) 229-6047. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on June 1, 2019. Life Online Counseling reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained by our therapists. We will provide you with a revised notice as required.

CREDIT CARD PAYMENT AUTHORIZATION

I understand that it is my responsibility to notify Life Online Counseling no less than 48 hours in advance if I need to cancel my appointment. If applicable, I further understand that my insurance company will not reimburse for missed appointments. Cancellations of an appointment less than 24 hours in advance and “no show” constitute a missed appointment and will be subject to a full fee for the appointment time. In the event of a late cancellation, no-show, or missed appointment, I agree to be responsible for the per session fee and authorize Life Online Counseling to charge my credit card for the amounts due.

I authorize Life Online Counseling to charge the credit card that I provide according to the terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.