Informed Consent for Psychotherapy and Practice Policies

Lance McGraw, PLLC 
3809 South Congress Avenue Suite 353 Austin, TX 78704 
Phone: (737) 443-0261
Email: lancemcgrawcounseling@gmail.com 
https://fourthwallcounseling.co

CLIENT SERVICES AGREEMENT AND CONSENT TO SERVICES

Welcome to Lance McGraw, PLLC. This document sets out important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between us. You may revoke this agreement at any time.

COUNSELING SERVICES AND SESSIONS

Psychotherapy is not easily described in general statements and varies depending on the problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that are discussed both during your sessions and on your own.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways.

Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, but there are no guarantees of what you will experience.

PROFESSIONAL FEES

We offer 50-minute counseling sessions. Our rate is $110 for individual sessions unless otherwise arranged by your therapist. Sessions that go longer than 60-minutes are subject to additional fees. You can schedule a session directly with your counselor. Fees will be collected when services are rendered. We require that you provide our office with a valid credit or debit card prior to your initial session. Your card will be charged at the time of your session. If payment is not made for three consecutive sessions, services will be suspended until payment is made. We are in-network for individuals with insurance through Cigna / Evernorth.

CHANGES AND CANCELLATIONS

We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and your therapist is happy to contact you for a session via our HIPAA-compliant telemedicine system so you don’t need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location where your counselor is licensed we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please let your therapist know by phone or email. Cancellations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your card at the time of your appointment.

Regular attendance and engagement are important elements of a therapeutic relationship. Clients are expected to attend scheduled sessions, and therapy services may be terminated if you are unable to attend a minimum of 75% of scheduled sessions. Use of alcohol and intoxicants is prohibited during sessions. Attending a session while intoxicated will result in cancellation of your session and a fee equal to the total amount of the scheduled session will be debited from your card at the time of your appointment. 

COURT TESTIMONY

We are not permitted by our ethics code to offer opinions on child custody matters and testimony will generally be limited to the information contained in the notes for your sessions.

  • Court testimony costs begin at $300 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at $.97/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance.
  • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer may be forfeited. If proper notice is given, the retainer will be refunded.
  • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $300 per hour, rounded to the nearest 15-minute increment.

EMERGENCIES

IF YOU HAVE AN EMERGENCY GO TO THE EMERGENCY ROOM NEAREST YOU OR CALL 911. There is no guarantee your therapist will be available to take your call, answer an email, or respond to a text in an emergency or crisis situation.

ELECTRONIC COMMUNICATION

We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. Communication via phone or email should be limited to scheduling and cancellations.

We request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

SOCIAL MEDIA

Social media, including but not limited to Facebook and Twitter, may be used by therapists in this practice as tools for marketing services and disseminating information. Social media of any kind are not secure in terms of privacy and confidentiality so our policy regarding the use of social media includes the following:

  • We do not provide therapy via social media.
  • Therapists will not acknowledge or return private messages delivered via social media.
  • Therapists will not acknowledge or respond to client emergencies delivered via social media.
  • If you have an emergency do not contact your therapist via social media. Instead go to the emergency room nearest you or call 911.

LIMITS OF CONFIDENTIALITY

The law protects the privacy of all communication between a client and a counselor. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by Chapter 181 of the Texas Health and Safety Code (HB 300) and HIPAA. There are other situations that require only that you provide written, advance consent which is provided by signing this document. Your signature on this Agreement provides consent for the following activities:

  1. Although you will meet with only one counselor, you are receiving services from the office of Lance McGraw, PLLC. We utilize Simple Practice, an online HIPAA-compliant data storage service to store client records.
  2. In providing, coordinating, or managing your treatment and other services related to your counseling care, Lance McGraw, PLLC sometimes interacts with other professionals concerning your well-being. An example of this would be when we consult with another healthcare provider, such as a physician. We will acquire a release of information to keep on file if such coordination is necessary.
  3. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, Lance McGraw, PLLC cannot provide any information without (a) your (or your legal representative’s) written authorization, or (b) a court order/subpoena.
  4. If we have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires us to file a report with the Texas Department of Child Protective Services. Once such a report is filed, we may be required to provide additional information.
  5. If we have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires your therapist to file a report with the Texas Department of Elder Protective Services. Once such a report is filed, we may be required to provide additional information. 
  6. If we believe that it is necessary to disclose information to protect against a risk of serious harm being inflicted by you upon yourself, another person, or to the community, your therapist may decide to take protective action. Depending on the situation, these actions may include contacting the police/or your emergency contact from your intake paperwork. If such a situation arises, your counselor will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.
  7. If you disclose past sexual abuse by a mental health provider the law requires that Lance McGraw, PLLC reports this to the proper authorities and licensing entities.

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

Additionally, If you and your therapist see each other accidentally outside of the therapy office, your therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge your therapist first, they will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.

COUNSELING VIA TECHNOLOGY

Online methods of providing counseling services are evolving all of the time. At Lance McGraw, PLLC, we will utilize those means ethically and therapeutically. Technology-assisted distance counseling for individuals, couples, and groups involves the use of the telephone or the computer to enable counselors and clients to communicate at a distance when circumstances make this approach necessary or convenient.

Tele-counseling involves synchronous distance interaction among counselors and clients using one-to­ one or conferencing features of the telephone to communicate. Video-based individual Internet counseling involves synchronous distance interaction between counselor and client using what is seen and heard via video to communicate.

In order to utilize technology for therapy, you must:

  1. Be an established client with intake paperwork, payment information, and an emergency contact on file.
  2. Be within the state of Texas, unless
    • You are a resident of Texas but you are temporarily located outside of the state.
    • You are a client newly relocated outside of Texas and you experience an emergency. In this case your therapist will provide triage and referrals to a local counselor in your state.
    • You are located on a US military base.
  1. Have a release of information for an emergency contact for the location from which you will be calling.
  2. Provide the address from which you are located.
  3. Assume responsibility for securing a location to speak with the therapist that is confidential. 
  4. Understand when communicating via technology, confidentiality cannot always be guaranteed.

PROFESSIONAL RECORDS

The laws and standards of our profession require that Lance McGraw, PLLC keep Protected Health Information about you in your Clinical Record. Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, and any reports that have been sent to anyone. You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted by and/or be upsetting to untrained readers. For this reason, Lance McGraw, PLLC recommends that you initially review them in your counselor’s presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, Lance McGraw, PLLC is allowed to charge a copying fee of $25 (and for certain other expenses). If Lance McGraw, PLLC refuses your request for access to your Clinical Records, you have a right of review, which a counselor will discuss with you upon request.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your therapist may terminate treatment after appropriate discussion with you and a termination process if your therapist determines that the psychotherapy is not being effective for you or if you are in default on payment. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source. Following termination, your therapist will serve as your Therapist of Record no more than 90 days. 

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

In the event of your therapist’s termination, death, or incapacity, all records created as a contract therapist with Lance McGraw, PLLC will be secured and archived on an encrypted electronic server. In the event of the closure of Lance McGraw, PLLC or the death or incapacitation of its owner, records created by contracted therapists will be secured and archived on an encrypted electronic server until the contents of Lance McGraw, PLLC are probated.

MINORS & PARENTS 

Clients under 18 years of age and their parents should be aware that the law may or may not allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, your counselor would provide them (if requested) only with general information about the progress of your treatment, and your attendance at scheduled sessions. If requested, your counselor could also provide parents with a summary of your treatment when it is complete. Any other communication to your parents will require your authorization, unless you meet the criteria set forth above under “Limits of Confidentiality.” Before giving parents any information, your counselor will discuss the matter with you, if possible, and do her/his best to handle any objections you may have.

COMPLAINTS

Although clients are encouraged to discuss any malpractice concerns with their therapist, you have the right to report your concerns to:

Texas Behavioral Health Executive Council George H.W. Bush State Office Bldg.
1801 Congress Ave., Ste. 7.300
Austin, Texas 78701
Tel. (512) 305-7700
1-800-821-3205 24-hour, toll-free complaint system

NOTICE OF PRIVACY PRACTICES

Lance McGraw, PLLC 
3809 South Congress Avenue Suite 353 Austin, TX 78704 
Phone: (737) 443-0261
Email: lancemcgrawcounseling@gmail.com 
https://fourthwallcounseling.co

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 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 certain 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 about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of 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, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

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 of 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 health care providers who have 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 own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of 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 full record and/or full and complete information in order 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 health care 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, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other 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. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

  1. 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: a. For my use in treating you. b. 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. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.
  2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
  3. 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:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
  2. 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.
  3. For health oversight activities, including audits and investigations.
  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
  5. For law enforcement purposes, including reporting crimes occurring on my premises.
  6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
  7. 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 therapy for the same condition.
  8. 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.
  9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws. 10 Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you 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 health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

  1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other 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 emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

  1. 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.
  2. 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.
  3. 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, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
  4. 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 other information that I have about you. I will provide you with a copy of your record, 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.
  5. 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, or health care operations, or for which you provided me with an 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.
  6. 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 from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
  7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right 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 of it.

CONSENT FOR TELEHEALTH CONSULTATION

LANCE MCGRAW, PLLC
3809 South Congress Avenue Suite 353 Austin, TX 78704
Phone: (737) 443-0261
Email: lancemcgrawcounseling@gmail.com
https://fourthwallcounseling.co

CONSENT FOR TELEHEALTH CONSULTATION

  1. I understand that my health care provider wishes me to engage in a telehealth consultation.
  2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
  3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
  4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

  1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
  3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
  4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

  • That I have read or had this form read and/or had this form explained to me.
  • That I fully understand its contents including the risks and benefits of the procedure(s).
  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.