The law (State and Federal) protects the relationship between a client, medication management team, and psychotherapist, and information cannot be disclosed without written permission. VBHS looks forward to helping you with your goals.
This information is about our office policies. This information is in addition to the Notice of Privacy Practices details. Please read them and discuss them with your therapist if you have any questions.
Process of Therapy:
In our first session, we will spend some time going through key points to ensure we both understand how we can work together. We welcome any questions from you in our first meeting and any time following. We will enter our relationship with optimism about our progress.
For therapy to be most effective, it is essential that you take an active role in the process. We encourage you to discuss your goals, expectations, and concerns at all points during our work together. We will revisit these goals throughout our work together, as these often change over time. As things improve, we may slowly reduce the number of sessions and space out our meetings. You may find it helpful to return periodically as life stressors arise. The Texas State Board of Examiners governs counseling activities for Professional Counselors for LPCs and the Texas State Board of Social Work Examiners for LMSWs. We do not provide custody evaluation recommendations, nor legal advice, as these activities do not fall within our scope of practice.
Medication Management:
Appointments:
Individual appointments are scheduled for 45-minute segments unless you plan an extended session. Initial appointments are scheduled for 60 minutes. At the end of each session, we will ensure the following session is scheduled. Your appointment time is held exclusively for you. Please arrive on time as you use your time when you are late.
Cancellations:
If you find it necessary to cancel an appointment, please do so at least 24 business hours in advance (i.e., if your appointment is the day after a holiday, notify us the first business day before the holiday), or you will be charged the FULL session fee to your credit card on file as a no-show/late cancellation fee. We may also choose to hold the session over the phone instead of in the office. If we do not hear from you after a missed appointment and have a reason for concern, we may reach out to your identified emergency contact to ensure your well-being. Please note that multiple missed/canceled appointments and late arrivals may require us to discontinue treatment. In this circumstance, we will discuss how we should proceed with you in person or by phone.
Confidentiality:
Trust is an essential aspect of the therapeutic relationship. Your confidentiality is my utmost concern for maintaining this trust. The information you share will be held confidential. We will ask for your consent before disclosing any information obtained from your sessions or in writing to any other person or agency, including family members. State law and the ethics of our profession protect your confidentiality, except in the following cases. If you seriously threaten to harm yourself or another person, the law requires your counselor to try and save you or that person. This notification may include notifying the victim, notifying the police, or seeking appropriate hospitalization. If we believe a child, elder, disabled person, or dependent adult has been or will be abused or neglected, we are legally required to report this to the authorities. If you send a health insurance claim form to your insurance for reimbursement, it will have a mental health diagnosis label and become part of your permanent medical record. This may be relevant
in situations where your medical record is necessary, such as, but not limited to, qualifying for insurance, such as life, health, or disability insurance. We may also be required to provide additional details about the nature of your sessions to support medical necessity. To provide you with the best service, we may consult with other mental health professionals about your case without revealing your identity.
If you are working with a Licensed Professional Counselor Intern or Licensed Clinical Social Worker Intern, your therapist is required to discuss your case on a regularly scheduled basis with his/her supervisor. The Supervisor is also required to maintain confidentiality.
Exceptions include:
☐ Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
☐ If a client threatens serious bodily harm to another person/s, I must notify the police and inform the intended victim.
☐ If a client intends to harm himself or herself, we will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, we will take further measures without their permission that are provided to me by law to ensure their safety.
Electronic Transmission:
We cannot ensure the confidentiality of any form of communication through electronic media, such as email and text. **You are advised that any email sent to us via a computer in a workplace environment is legally accessible by an employer. ** When you send an email, it has the potential to be seen by many people before reaching its destination. For this reason, we will never discuss anything clinical with you via email and ask you to refrain from doing so. Text messaging and email will be used for administrative tasks only. We may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. We do not always check our email daily.
Records:
We are required by law to maintain records of each time you meet or talk on the phone. These records include a brief conversation synopsis and any observations or plans for the next meeting. If records are requested for any purpose, our policy is to provide an appropriate summary, as records can be misinterpreted. VBHS documents encounter in a secure Electronic Health Record System (EHR).
Risks:
In therapy and medication management, major life decisions are sometimes made, including changing employment/career and lifestyles. It is also possible that as a result of our work together, you may wish to adjust how you interact with people in your life. That may mean engaging in some relationships more or disconnecting from other relationships. The decisions are a legitimate outcome of the counseling experience due to an individual’s calling into question many of their beliefs and values. We will be available to discuss your assumptions or possible adverse side effects in our work together. We cannot guarantee that you will see improvement in your relationships or emotions due to our work together. Therapy and or medication management requires multiple things to be considered “successful.” These include involvement from you, a comfortable connection between us, and clear expectations for what may be possible due to our work together. Sometimes, therapy and medication management may bring up unexpected emotions or reactions to relationships. Some things we discuss may surprise you as you learn more about yourself.
Fees and Payment:
Full payment is due at the time of service, including testing fees. Payment methods include Cash, Visa, MasterCard, Discover, and FSA/HSA cards. We require that a credit card be placed on file to secure your appointment, but you are free to use any payment method at the time of service. You may also update/change your card on file at any time. In addition to the regular session fee, you may incur fees for the following services. This will be discussed with you before providing the service: – Testing, including personality, premarital, career, or psychological testing. – Non-admin related phone/email communication with your therapist greater than 5 minutes (billed in 15 min increments) – Report writing and preparation (i.e., for disability, legal or other purposes) – Court/attorney consultation or time spent in litigation – Banking fees charged for returned checks. You may receive a receipt for your payments upon request. If no other payment method is provided, we will charge your card on file at the time of service. Telephone conversations, site visits, report writing and reading, consultation with other professionals, the release of information, reading records, longer sessions, travel time, etc., will be charged at the standard rate in the fee schedule unless indicated and agreed upon otherwise. Cost of business increases may occur periodically. You will be notified well in advance of any increase. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. If requested, we will provide you with a copy of your monthly statement via the client portal, which you can then submit to your insurance company for reimbursement if you choose. You must be aware that insurance companies reimburse not all issues/problems dealt with in counseling. Filing may require releasing confidential information, such as mental health diagnoses, which could be utilized in future insurance decisions. You are responsible for verifying the specifics of your coverage and determining if pre-authorization is required.
Emergencies:
If an emergency for which you feel immediate attention is necessary, please get in touch with emergency services (911) immediately, the 24-hour MHMRA Helpline, 713-970-7000, who will determine the need to go to the Psychiatric Emergency Service located at 1501 Taub Loop in Texas Medical Center (24-7 walk-ins), or go to your nearest hospital emergency room. I will follow those emergency services with standard counseling during regular business hours. Remember that while we may be in the office, we do not answer the phone while in session with a client. Please do not use e-mail, text, and faxes for emergencies. The Clinic will eventually offer crisis intervention services. We will inform members of this
services.
Litigation Limitation:
Due to the nature of the medication management and therapeutic process and the fact that it often involves making a full disclosure about the many matters which may be confidential, it is agreed that should there be legal proceedings (such as but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you (client’s) nor your attorney’s, nor anyone else acting on your behalf will call on Victoria Behavioral Health Services to testify in court or at any other proceeding, nor will disclosure of the psychotherapy and medication management records be requested unless otherwise agreed upon. If you do become involved in litigation requiring your therapist or Medication
management team’s participation, you will be expected to pay for the professional time even if your team is compelled to testify by another party.
Social Media Policy:
We maintain multiple business social media accounts for the Clinic. These accounts serve to offer encouragement and resources. They are not a substitute for treatment by a licensed mental health professional or Medical Professional; nothing shared should be interpreted as a personal message. We do not interact with clients via social media. We also do not expect you to follow any of our accounts based on our work. If you follow one of our accounts and reach out to us via that method, we will discuss that further in our next session. We may remove your communication/comment/message from my account if we feel it violates your confidentiality. To protect the boundaries of our relationship, no connection will be created to any staff, therapist, or medical professional’s social media accounts, such as Facebook, Twitter, LinkedIn, etc.
Online/Phone Counseling:
You can elect to schedule your appointment via phone or webcam if you cannot make it to the office, reside further away, or prefer distance counseling/medication management. By signing this consent form, you understand and agree to the following:
☐ Distance counseling relies on technology that may involve a shutdown or disconnect in the middle of a session. We cannot be held responsible for unforeseen problems due to technical difficulties. Should a disconnect occur, the client will attempt to establish a reconnect by either phone or computer as soon as possible.
☐ You understand that online and telephone counseling is not appropriate if you experiencing a crisis or having suicidal or homicidal thoughts.
☐ To have a release of information for an emergency contact for the location from which you will be calling. – To be domiciled (primary residence) in Texas or be located on a US military base if outside of Texas.
☐ Online/phone counseling is only available when scheduled within a regular appointment time.
☐ There are both benefits and drawbacks to distance counseling. Online/phone counseling sessions may not be as complete as face-to-face services. If my counselor believes another service would better serve me, I will be referred to a counselor who can assist in my area.
☐ You understand that distance counseling is not a substitute for medication under the care of a psychiatrist or doctor.
☐ We do not agree to have sessions recorded.
☐ Please specify your preference for the phone (and provide your preferred number) or video when scheduling. All confidentiality during phone or video conferencing is subject to the rules and limitations within the product used. You understand that communicating via technology, confidentiality cannot always be guaranteed.
Notice of Privacy Practices
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on February 8, 2023.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting your health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with specific legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you how I may use and disclose your health information. I also describe your rights to the health information I keep about you and the obligations I have regarding using and disclosing your health information. I am required by law to: Make sure that protected health information (“PHI”) that identifies you is kept private. Give you this notice of my legal duties and privacy practices with respect to health information. Follow the terms of the notice that is currently in effect. I can change the terms of this Notice, which will apply to all information I have about you. The new Notice will be available in my office and on my website upon request.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment or Health Care Operations: Federal privacy rules (regulations) allow healthcare providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s treatment, payment or health care
operations. I may also disclose your protected health information for the treatment activities of any healthcare provider. This, too, can be done without your written authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosing and treating your mental health condition. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the whole record and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between providers, and referrals of a patient for health care from one health care
provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, you may disclose health information in response to a court or administrative order. I may also disclose health information about my child in response to a subpoena, discovery request, or another lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
II. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
For my use in treating you. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. For my use in defending myself in legal proceedings instituted by you. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. Required by law, and the use or disclosure is limited to the requirements of such law. Required by law for certain health oversight activities about the originator of the psychotherapy notes. Directed by a coroner who is performing duties authorized by law. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, the use or disclosure complies with and is limited to the relevant requirements of such law. For public health activities, including reporting suspected child, elder, or dependent adult abuse or preventing or reducing a serious threat to anyone’s health or safety. For health oversight activities, including audits and investigations. For judicial and administrative proceedings, including responding to a court or administrative
order, my preference is to obtain Authorization from you before doing so. For law enforcement purposes, including reporting crimes occurring on my premises. To coroners or medical examiners when such individuals perform duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of treatment for the same condition. Specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional
institutions. For workers’ compensation purposes. Although my preference is to obtain Authorization from
you, I may provide your PHI to comply with workers’ compensation laws.
10 Appointment reminders and health-related benefits or services. I may use and disclose your PHI contact to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives or other healthcare services or benefits.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or another person that you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergencies.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, at home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and additional information that I have about you. I will provide you with a copy of your document or a summary of it if you agree to receive a summary within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, healthcare operations, or for which you provided me with Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time.
I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing data. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy.
Acknowledgment of Receipt of Privacy Notice Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking
the box below acknowledges that you have received a copy of the HIPAA Notice of Privacy Practices.
Grievances:
If you are displeased with what is happening in therapy, I hope you will discuss your concerns with me so we can attempt to redirect and explore different methods for your treatment goals. I will also ensure you are referred to another practitioner, as mentioned above, if needed to continue your therapy. I am always open to feedback and take it seriously with care and respect. If you believe I was unwilling to listen or respond appropriately, you can
file a complaint with the Texas State Board of Examiners of Professional Counselors by mail at Complaints Management and Investigative Section, P.O. Box 141369, Austin, Texas 78714-1369 or call 1-800-942-5540. Our Notice of Patients Rights and Informed Consent is subject to change. If we change our notice, you may obtain a copy of the revised information by contacting us via email at contact@vbhservices.org.
