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This form is called a Consent for Services (the "Consent"). Your therapist has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Clinician.

Therapy is a collaborative process where you and your Clinician will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Clinician have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Clinician. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. First, you will review your Clinician's policies and procedures, talk about fees, identify emergency contacts, and decide if you'd like to submit to your insurance company as an out- of-network Clinician. Second, you will discuss what to expect during therapy, the length of treatment, and the risks and benefits of counseling and the frequency of your sessions. Third, you will form a treatment plan to include how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Clinician may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Clinician's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

I realize that my child’s counseling is confidential. Information may not be released without my written consent except in the event that an issue is raised which in the counselors judgment would endanger my child’s welfare. I would be notified, as would appropriate authorities and resources, if indicated.
My child’s Clinician may determine with my child that my participation is needed to treat a specific problem.

To use telehealth, you need an internet connection and a device with a camera for video. Your Clinician can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Clinician will recommend a different option. There are some risks and benefits to using telehealth:
• Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Clinician carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Clinician will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Clinician to provide immediate support during an emergency or crisis. You and your Clinician will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
• Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Clinician for their permission in advance.
• Make sure to let your Clinician know if you are not in your usual location before starting any telehealth session.

Your Clinician will not disclose your personal information without your permission unless required by law. If your Clinician must disclose your personal information without your permission, your Clinician will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Clinician may speak to other healthcare Clinicians involved in your care.
• Your Clinician may speak to emergency personnel.
• If you report that another healthcare Clinician is engaging in inappropriate behavior, your Clinician may be required to report this information to the appropriate licensing board. Your Clinician will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Clinician must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Clinician may not keep your personal information confidential.
• If your Clinician believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Clinician can explain more if you have questions.
• If your Clinician has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Clinician believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Clinician will work with you to discuss other options to keep you safe.

Your Clinician is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

You decide how to communicate with your Clinician outside of your sessions. You have several options:
• Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
• Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Clinician will discuss options available to you. If you decide to be contacted via non-secure methods, your Clinician will document this in your record.
• Social Media/Review Websites
• If you try to communicate with your Clinician via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your Clinician may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Clinician on any platform, they will not follow you back.
• If you see your Clinician on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Clinician. If you choose to leave a review of your Clinician on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing in other places without your knowledge.

You will be required to pay for services and other fees. You will be provided with the cost of services. Therapy at Summit Counseling and Consulting is self-pay. You agree to pay at the time of service. You will be given notification on how to reach out to your insurance company to see if you have out-of-network benefits in which you can request a superbill to submit on your behalf for reimbursement.
• No-Show and Late Cancellation Fees
• If you are unable to attend therapy, you must contact your clinician before your session. Otherwise, you may be subject to fees outlined in your fee agreement. Insurance does not cover these fees.
• Balance Accrual
• Full payment is due at the time of your session. If you are unable to pay, tell your clincian. Your clinician may offer payment plans or a sliding scale. If not, your Clinician may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
• Administrative Fees
Fees are inclusive of all services rendered, meaning if I coordinate services or consult with another Clinician/school, write letters/emails, there is no extra charge. However, if requested to attend a professional meeting outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. The fee will be the same as your hourly session fee per agreement. Payment is due in advance.
• Insurance Benefits
• Before starting therapy, you should confirm with your insurance company if:
• Your insurance has out-of-network benefits for psychotherapy. If so we can provide superbills for you to submit to your insurance company for reimbursement.
• Sharing Information with Insurance Companies
• When your Clinician is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Clinician; however, all fees will be due at the time of your session to your Clinician. Your Clinician will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

If you feel your Clinician has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Clinician's license @ the NH Board of Mental Health or the US Department of Health and Human Services.

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