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

The Therapeutic Process:

You have made the first step on your road to feeling better by contacting a therapist. Like every important decision you make in your life, you may want to talk to several therapists about their training, treatment approach, fees, and so on. “Shopping” for a therapist is often vital in getting the satisfaction you want from therapy.
If you decide to enter therapy with one of Insight's Counselors, they will initially spend time with you exploring the problems which brought you to therapy. Next, you will work with them to set specific goals which you wish to work towards in therapy. Your progress in therapy will be periodically reviewed. The length of therapy will vary depending upon the type and amount of concerns you bring to therapy. At times, changes brought by your efforts in therapy may cause some discomfort or anxiety; your feelings should be discussed with your counselor. These feelings often accompany behavioral change, and are often a sign of progress. Your counselor can discuss with you other forms of therapy that you may decide would be more appropriate, such a referral to group therapy, a psychiatrist, a specialist in the area, or other forms of therapy. Please be advised there are risks associated with therapy and with change, and that this process can be difficult and time consuming.

Confidentiality:

As a client, one of the most important rights is that of confidentially. Information obtained during therapy sessions will be held confidential, and will not be disclosed to anyone outside of therapy without your consent. If you are attending therapy as part of a couple or family, you may at times see your counselor without your partner or other family members present. Remember that one record is kept for family, sibling, or couple work. If you have other family members present from time to time for therapy, remember that we cannot release records without signatures of all parties involved. In this instance, if information is divulged to your counselor and they think it is important for you to share with your partner or other family members, or if you present a situation which is blatantly harmful, unfair, or unethical, they may: (1) ask you to divulge this information before therapy continues, (2) ask your permission to divulge the information before therapy continues, (3) discontinue therapy if options (1) and (2) are not met. There are also a few exceptions to confidentially as defined by law to which you should be aware. Our therapist are required to break confidentially if one or more of the following conditions exist:

1. If your counselor has reason to think that you (clients involved in therapy) may be harmful to yourself or others.
2. If your counselor suspects that child abuse or neglect has occurred.
3. If court orders the release of information regarding your treatment.
4. If you fail to make payments and receive 2 notices in the mail, it is possible Insight will turn your information to a credit agency, see below under office procedures and fees.
5. Confidential information may not be released without written consent except in emergency as provided in General statutes, except in event of audit, request from funding source, or emergency treatment.
6. By signing on the last page of informed consent, you recognize these have been explained.
Minor’s Confidentiality
When working with clients who are minors we will obtain consent from a parent or legally authorized representative. All relevant court and custody documents will be required prior to seeing a minor in therapy. This is used to verify custody to ensure the consent for treatment is appropriately and legally obtained. For children who are clients, it will be determined the extent that he or she understands privacy based on chronological age and cognitive ability. If the child has no concept of privacy, then I am free to share information with parents without informing the child first. Pre-adolescents and adolescents will be seen on an” informed forced consent” in that information will be handled as confidential, but it is up to the therapist to decide what information is pertinent to share with the parents. Sometimes it is in the best interest of the minor client not to disclose all information to the parents that the child shares with the therapist so as to strengthen the therapeutic alliance and work through issues with the minor. Parents of the minor will be given updates of progress of goals and treatment plans on a scheduled basis. When it is determined that information should be shared for therapeutic reasons or as part of family counseling, the client will be informed and consulted and/or included in sharing the information to the parents or guardians. This of course, is superseded by any of the exceptions of confidentiality (danger to self or others, abuse, or court order) as stated in the above paragraph.

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

Insight Professional Counseling Services, PLLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.


YOUR RIGHTS
Consumer Rights as defined in NC laws and rules (APSM 95-2, G.S 122-C)
As a Client you have the right to:

1. Ask questions at any point in time regarding therapeutic or office procedures.
2. You have the right to be informed of rights at intake by this informed consent, and HIPPA laws.
3. You have the right to contact and consult with legal counsel, private practice physician, and professional of your choice.
4. You have the right to a consumer advocate.
5. To receive necessary treatment.
6. Consumer should be informed of benefits, potential risks, and other forms of treatment.
7. Terminate therapy at any time without threat or termination of services, you may ask your counselor for a list of possible referral sources. Written discharge plan at time of discharge. You have right to terminate therapy at anytime.
8. Specify and negotiate therapeutic goals and be an active participant in therapy.
9. Confidentiality, as described above.
10. To receive copy of HIPPA and privacy notice forms (by signing below, you agree that you received a copy and understand the policy)
11. Be apprised of fees and payment policies to include no surprise act quote if paying out of pocket.
12. Ask about alternative procedures available for meeting your goals.
13. The right to be treated with dignity and respect.
14. To be free from abuse/neglect, and exploitation.
15. Consumers should be apprised in HIPPA about how to file grievances if needed.
16. To have written treatment plan, and have a copy of your treatment plan. Ask clinician for copy first visit.
17. To contact the Disability rights North Carolina, formerly known as Governors Advocacy Council for People with disabilities at 1-877-235-4210, or 919-856-2195.
18. Individual has right to treatment, including access to medical care and habilitation, regardless of age or degree of MH/DD/SA disability. Individuals have the right to access medical care for treatment of physical ailments.
19. Consent for release of information is voluntary, however coordination of care is vital in many cases
20. Confidential information may not be disclosed without written consent when federal statutes prohibit that release.
21. Client has the right to file a compliant with your therapist board. See below.

Each session hour is normally fifty three minutes in length or 75 minutes depending on recommendations. Fees ran due to insurance contracts. Insight will be billing under your current BCBS, UHC, Wellcare Medicaid number/card, AETNA, Healthyblue, Healthyblue Care Together, Complete Care, Amerihealth, UHC medicaid, Cigna number electronically however not all clinicians are on all panels and should read their professional disclosures to make sure they take your insurance. WE ARE NOT ON EAP PROGRAMS regardless of what they say on their websites. By signing this form, you agree for us to bill electronically. If insurance is not being filed, we will expect full payment after services are rendered. Cash, credit or debit cards are accepted methods of payment. By signing below, you agree to pay for any portion of professional fees not reimbursed by insurance. Please remember if you have a deductible, you must pay the full amount of the session and we will file towards the deductible. The payment authorization form signed gives us permission to bill your card for the remainder of what's not covered, and the system will bill your card for any fees not covered as soon as we receive the EOB. After your deductible is met, you will be responsible for your co-payment. It is the client’s full responsibility to explore what insurance covers and does not cover, and will pay anything that their insurance company refuses to pay. Medicaid does not require deductible and therapy is fully covered. We are now on all standard Medicaid panels: Wellcare, Healthyblue medicaid, Healthyblue foster care medicaid, UHC medicaid, Amerihealth, Complete Care. Our policy changed to billing credit cards through our HIPPA system, therapynotes.com, and everyone is required to put a credit card payment authorization on file. Some clinicians require assessment fee for Prepare and Enrich for Couples therapy, a onetime $100.00 fee, not reimbursable by insurance. This covers assessment using PREPARE/ENRICH , results, and a couples workbook. If we need to issue a refund, it will go back to the card on file, and the card that was charged.

Beginning in 2026, couples counseling will be offered as a self-pay service at our practice. Insurance companies do not recognize “true” marriage or relationship counseling as a medical service, and there is no CPT code for couples counseling when the focus is on relationship dynamics rather than a mental health diagnosis. Relationship counseling alone is not considered a medical diagnosis and therefore is generally not reimbursable by insurance. In some situations, after a clinician has worked with a couple for an appropriate period of time, it may become clear that the marital or relationship concerns are primarily related to one partner’s diagnosable mental health condition. In those cases, the clinician may determine whether it is ethically and clinically appropriate to bill sessions to insurance under that individual’s diagnosis. This determination must meet strict ethical and documentation standards, including: The session must focus on the medical necessity, diagnosis, and treatment goals of one identified client.
The chart must be maintained under that individual, which may limit the other partner’s access to records. All issues addressed in session must be clearly tied back to the diagnosed condition. We also want to be transparent that insurance restrictions often limit the amount of time and flexibility clinicians have when working with couples. For many clients, this does not allow us to provide the depth and quality of care that couples deserve when doing true relationship work. For these reasons, couples counseling will be offered at a self-pay rate of $150 per session when the focus is on genuine relationship and marital counseling. If, over time, a clinician determines that all presenting concerns can be ethically and clinically justified under one partner’s diagnosis, the self-pay rate and the possibility of billing insurance may be re-evaluated. Our goal is to provide high-quality, ethical, and transparent care while honoring both clinical best practices and insurance regulations. There is an additional consent for this service that must be agreed upon before starting sessions.

When one of our providers are not yet credentialed under a particular insurance company, all insurances except UHC in our state allow for us to bill under the supervisor within our group. It takes time to credential our therapist and to enroll them under the group for insurance. Behavioral health providers can bill for services within their scope of practice that are rendered by supervises if under the same group. Due to this there are times that your billing statement may have the billing supervisor as the rendering provider under our group instead of your current counselor listed on your statement. This is acceptable and if you arent sure if provider at our practice, please check website for all of our current clinicians. We start credentialing counselors as soon as they join our practice, but we can not control how long insurances take to credential and enroll.

Use of Diagnosis
Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require that a diagnosis of a mental-health condition and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.


After 2 notices of late payments Joanna has the right to turn over to credit agency. If we must employ collections services or legal fees due to the collections process, these fees are added to client’s balance. I understand that Insight may utilize all legal means to collect any debts owed on past due accounts, including collections procedures which might disclose my name and other personal information, limited only to the purposes of the collections process. I realize no treatment information other than dates of service will be disclosed for collections purposes. Insight practices in compliance with HIPAA privacy standards.

Insight will offer text/email reminders from our TherapyNotes Patient Appointment Reminders feature that is HIPPA compliant. Please note that once you make an appointment with your clinician, you are responsible for this appointment even if you do not get a reminder. By signing below, you agree to text/email reminders and please make sure we have your correct telephone number and/or email. Email reminders are sent about 2 days before the appointment and text or phone reminders are usually sent one day before the appointment. Patients can opt out of receiving reminders at any time at our patient portal site, TherapyPortal.com, which will have additional features added over time. We have a patient portal that will allow patients to fill paperwork out before the visit and must be completed before initial appointment. When you receive the email, it will say “Welcome to the client portal for Insight Professional Counseling Services, PLLC”. Please use this convenient resource to log in to review and sign documents sent to you by the practice. Please fill out all of the requested important documents.
Our practice uses Telzio as a virtual HIPPA compliant phone system. We have Virtual Assistants With CIRRUSA who assist with scheduling appts and handling the beginning stages of appointments such as sending documents through the portal, communicating about reminders, and sending insurance to our medical biller. Some of our providers use a Telzio virtual cell phone number that they will share with you to allow for HIPPA compliant messaging when needed. You will receive a consent form at your first session if you would like to allow for Telzio messaging.

Keeping track of scheduled appointments is the clients’ responsibility, and we cannot be held responsible for missed appointments due to clients’ poor planning or organization. Appointments are scheduled at a specific time, and we request that clients arrive on time. In the occasional event that clients are late, we will wait 15 minutes, but would expect a phone call to hold that time open. We offer a forgiveness policy and will accept one missed appt (but will charge), at that time, if there is a second missed appointment, your contract with therapist will be terminated and you will be giving referrals.

When sending a fax or asking other professionals to send faxes, please advise them to make sure there is a cover letter attached to protect confidentiality. Insight uses faxage and is shared by all clinicians at Insight. Our fax number is 336-792-1029.
As part of their ongoing commitment to provide the best possible service, your provider may opt to use an artificial intelligence note-taking tool that assists in generating clinical documentation based on your sessions in our HIPPA compliant EDI system. This allows for more time and focus to be spent on our interactions instead of taking time to jot down notes or trying to remember all the important details. A temporary recording and transcript or summary of the conversation may be created and used to generate the clinical note for that session. Your provider then reviews the content of that note to ensure its accuracy and completeness. After the note has been created, the recording and transcript are automatically deleted. This artificial intelligence tool prioritizes the privacy and confidentiality of your personal health information. Your session information is strictly used for the purpose of your ongoing medical care. Your information is subject to strict data privacy regulations and is always secured and encrypted. Stringent business associate agreements ensure data privacy and HIPAA compliance. Please discuss any questions or concerns you may have about this feature with your provider, and you can withdraw this consent at anytime. Send an email to your provider if you would like to withdraw a consent.
Phone consultations (different than telehealth) are sometimes appropriate but will also be billed the same amount for a session fee. You will be required to bring payment at your next appointment time if you require a phone consultation. Phone consultations are not normally reimbursable by insurance, so please be prepared to pay this out of pocket fee. Phone consultations are $60.00 for 30 minutes, and $90.00 for 45-60 minutes. If clients need to speak briefly with their therapist over the telephone in between sessions, they may call the office phone. Please remember we are with clients most of the time. You may leave a voice mail if we are unavailable and we will return your call as soon as possible. Calls under 15 minutes are not considered telephone consultations, and there is no charge for them. Sending medical information also applies and depending on how much time your clinician spends, you will be charged for medical request. Fees above are applicable to sending medical files.

Our counselors fully believe in collaborating together to develop a termination plan when discharge is appropriate. If we have not heard from you in two weeks, and /or you are not returning phone calls and/or following treatment plan of sessions, we will assume that you are terminating our therapy agreement. There will be a note placed in the file stating that you were not part of the termination plan and you will be discharged. If later you feel you need treatment, you may contact us for another intake appointment or referral depending on our counselor's availability.

We ask that we have releases signed for collaboration with primary care physician. If you are referred by a physicians office, they often contact us to collaborate about the first appointment to make sure we solidified an appointment with you. By signing below , you give us authority to confirm an appointment exist if your referring provider reaches out but with no details until release signed. This is voluntary however, vital to your treatment. Many insurances require this as well. Best practice is that at the very least, a discharge summary is sent to primary care so that they know therapy was provided and any diagnosis and treatment recommendations.

Upon arrival to the office, please have a seat in the waiting area until your counselor comes out to greet you. Please text your clinician when you arrive, and your clinician will let you know when they are ready. We do not have a receptionist. Parking is limited, and you may have to park on the road, or if dropping off a client, not waiting in parking lot. In the Liberty office, you can park on the road or behind the building. Please supervise children and do not allow them to take products from the kitchen such as waters, food in refrigerator, etc. Also remember that this is a professional office and a therapeutic environment, and it is important to wait quietly. Our policy for medical record retrieval is to allow for 30 days. If an agency request them and has an appropriate release, we will notify them of my policy. We will file an incident report when an emergency occurs to secure proper documentation regarding events that occur while in our care. If after hours, the door may be locked for safety purposes, and you will need to text your clinician that you have arrived.

To insure quality control in therapy, we reserve the right to consult with therapist-colleagues regarding your treatment. This is similar to a physician “getting a second opinion”, and can be very helpful in therapeutic treatment. If consultation occurs, identifying information, such as your name, will not be discussed during these consultations.
Therapy has potential risks and rewards and your therapist should discuss these with you as part of the informed consent process. It is important that you understand the risks and benefits (as well as your rights and responsibilities as a client in counseling) before embarking on treatment because you will be asked to work in partnership with us to determine how we approach your treatment. Some of the benefits include having an advocate to help you work through goals, and providing an open space to process feelings to better help your functioning. Some other benefits include but not limited to:
improved relationships
improved communication skills
improved coping skills (stress relief)
clearer personal goals
Ability to set boundaries
More confidence
Coming to terms with past experiences
Decreased levels of depression and anxiety
A caring, interested listener focused on helping you
Increased self-acceptance
Health care professionals are responsible for planning spaces and make appropriate safeguards for patients, and examine relevant local, state and federal policies to ensure appropriate accommodations. Our practices understand the importance of creating an intimate and friendly space to facilitate desired therapeutic response. Plants, artwork, client’s rights, therapist contact information, soothing, spa music and displaying credentials are important factors that we value in our space. Our space features dimed and soft lighting since more pleasant, relaxing, and calming than bright lighting, and natural light. We carefully planned spaces that are appealing across ALL demographics. We also have white noise machines and additional soundproofing efforts that help to create more privacy. We also thought about the configuration of chairs and other furniture in the waiting area, with two separate spaces, as well as the ability to wait in the car and text the clinician to safeguard confidentiality when necessary. Since Insight and Reclaim are two separate groups, we understand the importance of two separate phone lines with separate cell phone numbers for each counselor. Room temperature also influences comfort and we hope to balance this with both counselors and clients. Our health care organization here considers an ideal range of comfortable temperatures for our workplace. Our health care provider team and professionals have made it a practice to ensure reasonable safeguards for individuals’ health information by speaking in closed room when discussing a patient’s condition, by avoiding using patients’ names in public hallways and waiting areas and posting signs to remind employees to protect patient confidentiality, by isolating and locking file cabinets or records rooms. Both groups have separate record storage , and do not have access to the other groups file cabinets, by providing additional security, such as passwords, on computers. Our Liberty office shares office suite with other tenants that have agreed to professional safeguards for the space, and we share a waiting room. Please discuss this with your counselor with concerns before your first appt.
The Privacy Rule requires a covered entity to have in place appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information (PHI), including reasonable safeguards to protect against any intentional or unintentional use or disclosure in violation of the Privacy Rule. We value and take maintaining personal information very serious. It is important to note that waiting rooms can pose hidden risks in terms of information. The very fact that a patient has to attend in person necessitates at least a minor breach of confidentiality, because there will almost always be other people in the waiting room observing the patient’s presence. This cannot reasonably be prevented. The risk of infection and virus and sickness is another that we will safeguard against but not guaranteed. One must understand coming in person poses risks.
We now have two buildings in Burlington and one in Liberty: 1205 S Main Street, and 1211 S Main Street, Burlington. 121 Swannanoa Drive Liberty.
Counselors in building 1211: Jennifer Simms (2 days), Kiana Carter, Emily Buckley, Katie Chrisco, Joanna Warren (few days), Nora Puryear, Whitney Rutter, Ricki Howell, April Creason, Halee Mazucca
Counselors in building 1205: Cari Sun, Alisha Miller, Lindsey Ballard, Renee Smith, Tiffany Hall, Joanna Warren, Monique Maness, Rebekah Mason, Melissa Hanold, Ashley Bledsoe (1 day), Kellie Johnson
Counselors in Liberty: Jennifer Simms (2 days), Rebekah Mason (1 Day), April Creason (1 day), Ashley Bledsoe (1 day)
At times, changes brought by your efforts in therapy may cause some discomfort or anxiety; your feelings should be discussed with your counselor. These feelings often accompany behavioral change, and are often a sign of progress. Your clinician can discuss with you other forms of therapy that you may decide would be more appropriate, such a referral to group therapy, a psychiatrist, a specialist in the area, or other forms of therapy. Please be advised there are risks associated with therapy and with change, and that this process can be difficult and time consuming. Often times, things get worse before they improve. Because therapy often means focusing on and talking about unpleasant or painful issues, in the near-term therapy can cause an increase in symptoms.
Although our agency consistently evaluates our services, we conduct yearly customer satisfaction surveys. In an effort to provide the best service possible, we will review these confidential documents, and makes changes appropriately.

If your treatment requires a school consultation, school observations, or meetings such as school, DSS, or other meetings that are not covered by insurance, our fees are $120.00 per hour for the amount of time outside of the office.

Because part of the goal of therapy is to protect confidentially, we ask that you not have your attorney subpoena us for testimony regarding divorce or child custody, in the event of such hearings. We will not make a custody recommendation, or a recommendation of where a child should live or visit, nor make determination to one's fitness as a parent. It is a conflict of interest and against guidelines for us to also be a custody or visitation evaluator in a case that our clinicians are providing therapy. We do not voluntarily go to court. We are NOT investigators If you do require us to testify in court on your behalf (going against our contract), we will bill you $1500.00 per appearance. This fee will be collected 7 days prior to court. Since I will be forced to clear my schedule of all appointments, and prior engagements, so that I may be available to appear in court, this fee is non refundable. If the court date is postponed and I must again clear my calendar to attend court you will again be charged the full 1500.00 fee. If your court date gets canceled, the fee is non refundable. Obviously, court appearances can be very costly and are not reimbursed by insurance. We will also bill you for 150.00 per hour for the amount of time for preparation in court. This will include court documents, consultation with attorneys, and another service associated with court. The documents will not be released until the amount in full that Insight has charged is paid in full. Also, this would be a break in our contract, which could lead to compromising our ability to work with you or your child in the future. It is your responsibility to let the other party know when signing this form that the therapist will not be going to court and if so, the fees will be charged and our contract will be voided. If another attorney subpoenas us such as DSS, or another party, you will need to discuss the fee, so that all parities understand. The actual client is the person who is responsible since our contract is with them, or if the child is the client, the legal guardian of the child. Also, your credit card on file will be charged for full amount owed due to court fees. In the event that your counselor needs to take files out of the office for court, case management purpose, school meetings, or to a location for a specific reason such as an audit, etc, your counselor safely secure the file in a locked briefcase, and will lock in the trunk of her vehicle. Also, our counselors do not make recommendations or statements regarding parenting decisions of any kind regarding emergency custody orders, custody, visitation, visits with parents, or make a recommendation on one's fitness as a parent. We believe its very important to stay neutral to our client, and families. As of January 1, 2023, if a client's parental unit is separated, we recommend that both parents agree to the process of therapy for the child, and is required if both parents have some form of custody (even if one party has authority to make legal and medical decisions). We recommend that both guardians are involved in treatment and are committed to the process, and we have found this works best with treatment for children. There are exceptions to this rule, but must be agreed upon on clinical team (outside clinical supervisors when necessary), and approval by our clinical directors and owner. Please ask your clinician or your intake coordinator for the policy for separated and divorced parents when working with minors. This policy must be agreed upon before working with our counselors.
Also its important to note that there are confidentiality risks involved with cell phones in the therapy room. Our clinicians have phones on for emergency and crisis purposes for our clients. If you bring your cell phone, you can simply turn it off, or turn off your voice assistance technologies. We have informed our clinicians to do so as well. Due to HIPAA, our practice and providers warn our patients that texting your clinician information can allow for risk of unauthorized disclosure to exist and if you choose this type of communication, you are consenting to communicate by text and understand the complications with PHI. Connecting with patients in real-time has become an effective, and convenient way to coordinate important relevant administrative information - from appointment reminders to rescheduling upcoming sessions. Even more, messaging with patients in real-time has also become an accepted form of ongoing care between patients and care providers with safeguards in place. We ask for patients to discuss preferred method of messaging and by signing below, one understands there are risks involved in this form of communication.

Good faith estimates are required by federal law if you are self paying costumer. It does not include any unknown or unexpected costs that may arise during treatment. Good faith estimates includes diagnoses of either Z73.3 , stress not elsewhere specified, or F99, Mental Health Disorder NOS, to satisfy the federal requirement. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed and sometimes within first 1-5 sessions. Please note your good faith estimate will be sent to you in your portal.

Emergency Information
When you sign the inform consent, you are giving your counselor authority to transport your child in case of emergency to hospital however your counselor doe not carry extra auto insurance for this matter. Please always update your information with your counselor such as emergency telephone numbers.

To insure safety in case of fire or disaster, please exit the building calmly down the hall towards the large exit sign. We will move to the parking lot behind the building beside our building for safety. There are fire extinguishers throughout our building and we are in compliance with fire safety with city of Burlington. The office staff will have a drill once a month for fire safety. In case of disaster or tornado, the plan is to move if there is enough time into a room in the center of the building away from any windows or doors. The same applies for Liberty office-Follow exit signs. Please remember Liberty has stairs.

First Aide supplies are located in the kitchen in the cabinet under the counter.


Facility Safety:
Please note that both of our Burlington offices have stairs as well as Liberty office. However, if you feel that the steps are unsafe for you, we will make an appropriate referral for a facility that would meet your needs or we can try to accommodate by using an office downstairs. The Liberty office does not have an option for downstairs. Please do not leave you children or teenagers unattended in the lobby unless you have specific permission to do so. Also, please do not leave your child outside to wait on their ride or unsupervised in the parking lot due to safety concerns. Parents are fully responsible for their children and teenagers while on the premises. Per federal law only trained service animals under American Disability Acts are permitted in office unless permission granted by therapist.

Additional Considerations:
To insure quality control in therapy, your counselor reserves the right to consult with therapist-colleagues regarding your treatment. This is similar to a physician “getting a second opinion”, and can be very helpful in therapeutic treatment. If consultation occurs, identifying information, such as your name, will not be discussed during these consultations. We are a group and follow all confidentiality appropriate best practice measures, and group administrative members such as owners, intake coordinator, and clinical directors have access to files, EDI system, and scheduling.

We have secured emails listed on the website if you need to send us an email. Our emails are secure and encrypted but that doesnt mean yours is. If you choose to send us an email, your confidentiality may be at risk. If professionals that I am collaborating with your consent would like to collaborate through emailing, then no names or identifying information will be discussed. In addition, we do have a personal Facebook profiles and social media; however. we do not accept friend requests from clients. We do not have a business Facebook page and instagram page for the practice. Our website has some great information for resources.

Also, from time to time, we have an intern seeking to gain counseling experience required for their licensure. Master level interns are able to provide counseling, assessment, under the direction of supervision, and your signature below indicates you are aware of this, and willing to work with an intern from time to time. Sometimes Interns sit in session with our counselors to learn and gain experience with your permission. They also act as intake coordinators that has access to scheduling and other needed administrative duties. If scheduling with an intern, the sliding fee scale is $35.00-$50.00 per session in 2026.


IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask in general areas is suggested but not required at this time;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.

TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. Our providers use several different platforms for telehealth to include therapynotes, zoom, psychology today, and DOXYME. If you sign on for telehealth services, you agree to these platforms. 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 Provider 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 Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider 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 Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

If using telehealth services, you are signing below that you understand you will not be in the same room as your provider. You also understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing, and there are potential risk to this technology, including interruptions, unauthorized access, and technically difficulties. You are also agreeing to understanding that your health care provider or you can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I understand the risks and benefits of telehealth, and any practice alternatives have been discussed with me in a language in which I understand
When signing below, you are consenting to use the Telehealth by TherapyNotesTelehealth by TherapyNotes , technology service and platform that we will use to conduct telehealth videoconferencing appointments, DOXYME, ZOOM, or psychology today, whichever is the preference of the provider. These are all simple, HIPPA compliant, and easy to use and internet based, and does not require downloading an app. A business agreement was established between these and providers are in place to establish guidelines.

You are also consenting to the following:
1.Telehealth is not an emergency service and in the event of Emergency, I will use a phone to call 911.
2.Though my provider and I may be in direct contact through telehealth, neither Zoom, Psychology Today or any telehealth service provides any medical or healthcare services or advice, including but not limited to emergency or urgent medical services.
3.The telehealth programs and videoconferencing is not responsible for the delivery of any healthcare, medical advice or care.
4.To maintain confidentiality, I agree to be in a private setting away from distractions and interruptions
5.Videoconferencing has limitations such as lighting, and buffering, please make sure you create a space where you are front-lit, and it is easy to see you and your expressions.
6 .Consider what is viewable behind you on the screen and make adjustments if needed.
7. Client will state present location in case of emergency to provider.
8.All of the programs requires a login and your provider will invite you to the link, and you will be in the clinician’s waiting room in your providers tab, and your clinician will videoconference you.
9.Most Insurance companies recognize this service as a billable therapy session with payment of services but co-payments, deductible, etc. will apply. Please check with your insurance and what is not covered is your responsibility. Some companies are not covering telehealth past March 2022, and this is your responsibility to know if this applies to you.


RECORD KEEPING
Your Provider 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. All clinical directors and owner, as well as intake coordinators have access to our EDI system for purposes of quality control and best clinical practice, as well as administrative duties needed.
Health Information Exchange Network
This facility participates in the North Carolina Health Information Exchange Network, called NC HealthConnex, which is operated by the North Carolina Health Information Exchange Authority (NC HIEA). We will share your protected health information, or PHI, with the NC HIEA and may use NC HealthConnex to access your PHI to assist us in providing health care to you. We are required by law to submit clinical and demographic data pertaining to services paid for with funds from North Carolina programs like Medicaid and State Health Plan. We may also share other patient data with NC HealthConnex not paid for with State funds. If you do not want NC HealthConnex to share your PHI with other health care providers who are participating in NC HealthConnex, you must opt out by submitting a form directly to the NC HIEA. Forms and brochures about NC HealthConnex are available in our offices and online at NCHealthConnex.gov. Again, even if you opt out of NC HealthConnex, we still will submit your PHI if your health care services are funded by State programs. Your patient data may also be exchanged or used by the NC HIEA for public health or research purposes as permitted or required by law. For more information on NC HealthConnex, please visit NCHealthConnex.gov/patients.

COMMUNICATION
You decide how to communicate with your Provider 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 and can change these settings in your portal. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method. Our email is encrypted but that doesnt mean your email is. By signing below, you are consenting to understanding that texting and emails can be hard to protect PHI and if you send a text to your provider, and choose this method, that you agree that there are risks involved.
• Secure Communication
Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, you may select this in your portal and choose to receive text messages.
• Social Media/Review Websites
If you try to communicate with your Provider 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 provider 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 Provider on any platform, they will not follow you back.
• If you see your Provider 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 Provider. If you choose to leave a review of your Provider 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 other places without your knowledge.


Insurance Benefits
Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive; if there is any mental health deductible
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
•Is telehealth covered ?

Sharing Information with Insurance Companies
• 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.

Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider 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.