GENERAL INFORMATION
The therapeutic relationship is unique in that it is a highly
personal and at the same time, a contractual agreement. Given this,
it is important for us to reach a clear understanding about how our
relationship will work, and what each of us can expect. This
consent will provide a clear framework for our work together. Feel
free to discuss any of this with me. Please read and indicate that
you have reviewed this information and agree to it by filling in
the checkbox at the end of this document.
THE PROCESS OF
THERAPY/EVALUATION AND SCOPE OF
PRACTICE
Participation in therapy can result in a number of benefits to
you, including improving interpersonal relationships and
resolution of the specific concerns that led you to seek therapy.
Working toward these benefits, however, requires effort on your
part. Psychotherapy requires your very active involvement,
honesty, and openness in order to change your thoughts, feelings,
and/or behavior. Shelley Tedder will ask for your feedback and
views on your therapy, its progress, and other aspects of the
therapy and will expect you to respond openly and honestly.
Sometimes more than one approach can be helpful in dealing with a
certain situation. During evaluation or therapy, remembering or
talking about unpleasant events, feelings, or thoughts can result
in you experiencing considerable discomfort or strong feelings of
anger, sadness, worry, fear, etc., or experiencing anxiety,
depression, insomnia, etc. Shelley Tedder may challenge some of
your assumptions or perceptions or propose different ways of
looking at, thinking about, or handling situations, which can
cause you to feel very upset, angry, depressed, challenged, or
disappointed. Attempting to resolve issues that brought you to
therapy in the first place, such as personal or interpersonal
relationships, may result in changes that were not originally
intended. Psychotherapy may result in decisions about changing
behaviors, employment, substance use, schooling, housing, or
relationships. Sometimes a decision that is positive for one
family member is viewed quite negatively by another family
member. Change will sometimes be easy and swift, but more often
it will be slow and even frustrating. There is no guarantee that
psychotherapy will yield positive or intended results. During the
course of therapy, Shelley Tedder is likely to draw on various
psychological approaches according, in part, to the problem that
is being treated and her assessment of what will best benefit
you. These approaches include, but are not limited to,
behavioral, cognitive-behavioral, cognitive, psychodynamic,
existential, system/family, developmental (adult, child, family),
humanistic or psycho-educational. Shelley Tedder provides
neither custody evaluation recommendation nor medication or
prescription recommendation nor legal advice, as these activities
do not fall within her scope of practice
TERMINATION
As set forth above, after the first couple of
meetings, Shelley Tedder will assess if she can be of
benefit to you. Shelley Tedder does not work with
clients who, in her opinion, she cannot help. In such
a case, if appropriate, she will give you referrals that you can
contact. If at any point during
psychotherapy Shelley Tedder either assesses that she
is not effective in helping you reach the therapeutic goals or
perceived you as non-compliant or non-responsive, and if you are
available and/or it is possible and appropriate to do, she will
discuss with you the termination of treatment and
conduct pre-termination counseling. In such a
case, if appropriate and/or necessary, she would give you a
couple of referrals that may be of help to you. If you
request it and authorize it in writing, Shelley
Tedder will talk to the psychotherapist of your choice in
order to help with the transition. If at any time you
want another professional's opinion or wish to consult with
another therapist, Shelley Tedder will give you a
couple of referrals that you may want to contact, and if she has
your written consent, she will provide her or him with the
essential information needed. You have the right to
terminate therapy and communication at any time. If
you choose to do so, upon your request and if appropriate and
possible, Shelley Tedder will provide you with names of
other qualified professionals whose services you might prefer.
CONFIDENTIALITY
In the following situations, authorization for release of
information is not required:
a) Clinical information about your case may be shared fully with
support staff for purposes of supervision where applicable. If
case information is presented at professional conferences, the
information will be disguised so that it is impossible to link
the information to you or your family. Shelley Tedder is an
independent provider of services that subleases space within
Living Perspective Counseling office. Case consultations with
colleagues are done periodically to provide clients with the best
possible care. In such situations, every effort will be made to
protect your identity.
b) Personal information is also shared for administrative
purposes such as scheduling, billing, and quality assurance.
Client files are also available to insurance company auditors.
Data contained in your file is available for archival research
(i.e., reviews of records to describe referrals, outcomes, and
trends) as long as your identity cannot be linked to the data
used. All staff members have been given training about protecting
your privacy and have agreed not to disclose any information
without authorization or approval by your clinician in mandated
reporting situations (see Limits to Confidentiality).
c) Please note that your counselor may use a "Practice Management
Provider". This is a 3rd party where your digital file is
kept and stored. The company that is utilized is HIPAA compliant.
d) On occasion, your clinician may find it helpful to consult
with another health or mental health professional. During such a
consultation, every effort is made to avoid revealing the
identity of the client. The other professional is legally bound
to keep the information confidential. If you do not object, it is
our policy to tell you about such consultations only if it is
important to you and your clinician working together. All
consultations are noted in the client's record.
e) Disclosures required by health insurers or to collect overdue
fees are discussed elsewhere in this agreement.
Limits to Confidentiality
In accordance with legal requirements, if instances of child
abuse, elder abuse, abuse of those who are disabled (mentally or
physically), threats of harm to self or to others, sexual or
physical misconduct by a licensed professional (medical
personnel, counselors, teachers, etc.) or clergy are revealed by
Client or observed by Counselor during the counseling process,
Client understands that Counselor has a legal duty to report any
such incidents to the proper authorities and licensing boards. As
pertains to any of these instances as detailed which are subject
to be reported to authorities, any information divulged by Client
in any session may be revealed in testimony if Counselor is
subpoenaed by said authorities in relationship to an alleged
threat, harm, or other alleged action deemed illegal. Client has
been informed that Counselor does not have privileged information
in court cases and that if the records are subpoenaed by the
court, then Counselor must turn them over. Client understands
that if information is released about a minor or elder who may be
abused by another party that the Counselor is legally required to
report those cases, even if the Counselor has not personally met
with that individual.
Financial. Client understands that if the payment is
made in the form of a check or credit/debit charge, that
confidentiality may be compromised by bank personnel or other
parties who may process that form of payment, including 3rd party
payers.
Insurance. If the Client decides to use their in/out of
network insurance benefits, then the Client understands that the
insurance company may request copies from the Client's treatment
record or information from it. Requests may include, but not
limited to, diagnosis, reported symptoms, treatment goals,
substance abuse issues, medical history, impact on job
performance, dates of service, types of service, treatment
compliance, medication compliance, contact Counselor has had with
Client's doctor, number of sessions used & needed for
therapy, prognosis, referrals given to the Client, etc. in order
for them to process a claim. Be aware that some jobs that the
Client applies to may ask about their mental health history and
if they used their insurance, then confidentiality may be
compromised. Some insurance companies use 3rd party payers to
process their claims instead of the claim being processed only
through the insurance company.
Other Instances:
Confidential information may be compromised if communication takes
place via the phone or e-mail.
In the case of natural or man-made disasters, fires, or burglary,
the Client's information may be compromised. The files in the
office are in locked drawers behind a double locked door. However,
should a disaster occur and the filing cabinets are destroyed and
the files are compromised, Client will not hold Counselor liable
for any information that was inadvertently released under the
before mentioned circumstances.
The Client understands that if the Counselor mails anything to the
Client's address, that confidentiality may be compromised by those
handling the mail who see the return address or those who may open
the Client's mail. It is the Client's responsibility to inform the
Counselor if he/she does not want use of certain forms of
communication.
Also, if unpaid bills have to be sent to a collection agency, then
confidentiality may be compromised as the collection agency will
need to know certain identifiable information about the Client in
order to pursue the past-due payments.
In instances where the courts may be involved, the Client
understands that if the Counselor's records are subpoenaed or court
ordered to be released that confidentiality may be compromised (see
Legal requirements and Legal actions).
If we see each other accidentally outside of the therapy office, I
will not acknowledge you first. Your right to privacy and
confidentiality is of the utmost importance to me, and I do not
wish to jeopardize your privacy. However, if you acknowledge me
first, I 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.
If any of these situations arise, your clinician will make every
effort to fully discuss it with you before taking action, and will
limit disclosure to what is necessary.
PROFESSIONAL RECORDS AND CLIENT RIGHTS
The laws and standards of the counseling profession require that
your clinician keep Protected Health Information (PHI) about you in
your clinical record. Generally, you may examine and/or receive a
copy of your clinical record if you request it in writing. There
are a few exceptions to this access: 1) some of the unusual
circumstances described above, 2) when the record makes reference
to another person (other than a health care provider) and we
believe that access is reasonably likely to cause substantial harm
to that other person, or 3) where information has been supplied
confidentially by others. Your clinician keeps no additional notes
(sometimes called psychotherapy or process notes) beyond the
clinical record. In most circumstances, your clinician is allowed
to charge a copying fee for re-producing your records (See Fees,
Billing, and Payment policies section of this document). If your
clinician refuses your request for access to your records, you have
the right of a review of this decision (except for information
supplied confidentially by others), which your clinician will
discuss with you upon request.
HIPAA provides you with several expanded rights with regard to your
clinical records and disclosures of protected health information.
These rights include requesting your clinician amend your record;
requesting restrictions on what information from your clinical
records is disclosed to others; requesting an accounting of most
disclosures of protected health information that you have neither
consented to nor authorized; determining the location to which
protected information disclosures were sent; having any complaints
you make about your clinicians policies and procedures recorded in
your records; and the right to a paper copy of this Agreement and
the privacy policies and procedures included herein. A detailed
version of HIPAA and your rights are included in the Notice of
Privacy Policy. Your clinician will be happy to discuss any of
these rights with you.
COMMUNICATION
Although they add convenience and expedite communication, it is
very important to be aware that computers and cell phone
communication can be accessed by unauthorized people, and can
therefore compromise the privacy and confidentiality of such
communication. E-mails, in particular, are vulnerable to such
unauthorized access due to the fact that servers have unlimited and
direct access to all e-mails that go through them. It is always a
possibility that e-mails and faxes can be sent erroneously to the
wrong address; and computers, including laptops, may be stolen.
If you need to cancel or change an appointment time; a telephone
call or text may get the message to your counselor in a timely
manner. Please notify your counselor if you decide to avoid or
limit, in any way, the use of e-mails, cell phones, text, or faxes.
If you communicate confidential or private information via text or
e-mail, your clinician will assume that you have made an informed
decision, will view it as your agreement to take the risk that such
communication may be intercepted, and your counselor will honor
your desire to communicate on such matters via e-mail/text.
Please do not use e-mail or faxes for emergencies. Due to computer
or network problems, e-mails may not be deliverable, and your
counselor may not check my e-mails or faxes daily.
Your clinician may prefer to use e-mail to arrange or modify
appointments only. If you e-mail your counselor content related to
your therapy sessions, please note that e-mail is not completely
secure or confidential. If e-mail communication outside of therapy
requires more than 5 minutes to read and respond to, your clinician
may charge for the professional services rendered in 15 minute
increments. Please indicate if you intend to pay these charges, or
your counselor will save it for review during your appointment
time.
If you choose to communicate with your counselor by e-mail, be
aware that all e-mails are retained in the logs of your and my
Internet service providers. While it is unlikely that someone will
be looking at these logs, they are, in theory, available to be read
by the system administrator(s) of the Internet service provider.
You should also know that any e-mails and text messages your
counselor receives from you, and any responses that your counselors
sends to you, becomes a part of your legal record and may be
revealed in cases where your records are summoned by a legal
entity.
If you do NOT want this option, due to concerns of
confidentiality, please do NOT use the online scheduling. Instead,
I encourage you to call me at 469-404-8725 and leave a message
directly on your counselor's voice mail. Your call will be
returned, usually within the same business day (within 24
hours/next business day).
Emails and texts taking longer than 15 munutes read and reply
will be subject to a fee of $15. Written communication deeemed
excessive by the counselor may be subject to additional fees and
will be addressed with client to discuss boundaries and possbile
higher level of care.
Telephone Accessibility
If you need to contact me between sessions, please leave a message
on my voice mail. I am often not immediately available; however, I
will attempt to return your call within 24 hours or next business
day. Please note that Face-to-Face sessions are highly preferable
to phone sessions. In the event you are out of town, sick or need
additional support, phone sessions are available (please see rates
under the Fees, Billing & Payment section of this document). If
a true emergency/crisis situation arises, please call 911 or go to
the nearest emergency room. Additional crisis resources are located
on my website www.shelleyteddercounseling.com.
Social Media
Due to the importance of your confidentiality and the importance of
minimizing dual relationships, I do not accept friend or contact
requests from current or former clients on any social networking
site (Facebook, Linkedin, etc.). I believe that adding clients as
friends or contacts on these sites can compromise your
confidentiality and our respective privacy. It may also blur the
boundaries of our therapeutic relationship. If you have questions
about this, please bring them up when we meet and we can talk more
about it.
AUDIO OR VIDEO RECORDING
Unless otherwise agreed to by all parties beforehand, there shall
be no audio or video recording of therapy sessions, phone calls,
or any other services provided by Shelley Tedder.
EMERGENCY CARE AND CRISIS SITUATIONS
Clients who are experiencing a crisis are encouraged to discuss
this with their clinician as soon as possible so a crisis plan
can be developed. A crisis may be generally defined as a
situation or period in which the person's usual coping resources
fail, and they experience a state of psychological disequilibrium
in which they may be at risk for impulsive or harmful behavior.
There are many examples of crisis situations, which may include:
a client who is struggling with suicidal thoughts, a teenager who
under distress runs away from home, a psychotic client who
experiences severe symptoms such as hallucinations or paranoia
because they have discontinued medications, and a client who
relapses to uncontrolled drug/alcohol use with danger of overdose
or serious harm. Such clients may or may not constitute an
imminent danger to themselves or others; nevertheless, sometimes
a judgment must be made to protect the client.
It is your clinician's policy, to which you consent as a client,
to provide conservative treatment during a crisis situation. Your
clinician will work with you to establish a plan to restore
normal functioning as soon as possible. In addition to coping
skills and possible environmental changes, this may include
consultation with your physician, or if necessary, a family
member or significant others. Your clinician may divulge your
client status and the minimal treatment information necessary to
protect you during a crisis period. The need for such action will
be discussed with you beforehand if at all possible. This
exception to normal confidentiality would remain in effect until
the crisis is over or your care has been successfully transferred
to another mental health provider or treatment program. This
crisis policy requires you trust in our professional judgment to
balance risks with your rights to confidentiality.
In times that your clinician is unreachable, the client who is
in an emergency is instructed to contact their physician or other
community resources directly such as 911 or MHMR Crisis Line
(800-762-0157). Additional crisis resources are located on my
website at www.shelleyteddercounseling.com.
If the Client is not honest with the Counselor regarding thoughts
of self harm (suicide or self injury) or harming of others when the
Counselor tries to assess for them, then Client and their heirs
will not hold the Counselor liable if the client decides to act on
those thoughts. If Client does reveal suicidal or homicidal
thoughts, then Counselor will ask them to sign a No Harm Agreement
and recommend a further evaluation at a hospital. If the Client or
their family decide not to follow the Counselor's recommendations,
then the Client or their family will not hold the Counselor liable
if some harm befalls the Client or another party, as the Client and
family acknowledge that they were noncompliant with treatment
recommendations that are documented during the session, email,
text, or phone call.
COUNSELING MINORS
In order for the Counselor to build a therapeutic relationship with
a minor and to find out important information to better assist the
minor client, it may be necessary for the Counselor to keep certain
pieces of information from their parent/guardian. In cases where
there is experimental drug use of non-lethal drugs, the Counselor
may not inform the parent/guardian. However, if the minor client is
regularly using certain substances, including alcohol, and shows no
signs of wanting to decrease said usage, then the parent/guardians
may be notified. If the minor client is using potentially lethal
drugs, then the parent/guardians may be notified after the first
instance of when the Counselor came to have that knowledge. In
cases of superficial, non-lethal, non-medical attention needing
self-injury, the Parent/Guardian may or may not be informed of the
injury. In counseling minors, the legal guardian/parent who is
bringing the minor to therapy understands that Ms. Tedder is not
allowed to make any statements regarding where a minor should live,
that she does not conduct forensic interviews, does not conduct any
tests or assessments that can be used in a school or court setting,
and does not conduct home studies.
Shelley Tedder is required to have a copy of the most recent
court documents detailing parental rights if one exists.
Counseling sessions will not be scheduled without this being
provided. If both parents have rights concerning the
psychological care, access to medical records/information for the
minor that is coming to counseling then current contact
information is required for both parents/guardians.
Sexual Relations Amongst Minors: In cases where the minor teen
(14 and above) is having sexual relations with someone who is
within 2 years and 11 months of their age and it is consensual,
then the Guardian may not be notified. DUTY TO REPORT: If the
Guardian or Counselor comes to have knowledge that their
child/Client is having sexual relations with someone who is
younger or older than them by 3 or more years and the minor
client is younger than 17 years of age, then the Guardian and
Counselor have a duty to report that to the proper authorities by
State law. To have such knowledge and not report is a crime in
the State of Texas by Penal Code 21. Clients who are 13 and
younger cannot consent to any type of sexual activity, even if it
is with someone of their own age. It is the policy of this office
to report any sex acts committed by minors ages 13 and younger to
CPS for review.** Example:** An 18 year old and 16 can date and
have sexual relations; a 17 year old and 14 year old can date but
not have any sexual relations; a 20 year old and 16 year old can
date but not have sexual relations; a 15 y/o and a 16 y/o can
date and have sexual relations; and a 13 y/o can date a 14 y/o,
but they **cannot have sexual relations. These instances are
reportable by law.
Child Pornography: a minor (17 and younger) commits a legal
offense if they take pictures/video of an undressed minor
(including themselves), keeps said data on their electronic
device (possession of child pornography), and/or transmits it in
any form or fashion (distribution of child pornography). Even if
the minor is sending pictures of him/herself to a significant
other, that still falls under the category of child pornography
and legally has to be reported. ***Caregivers are encouraged to
monitor their minor's social media accounts and electronic
devices on a regular (minimum of once a month) basis.
MARITAL THERAPY/COUPLES THERAPY
If the Counselor is conducting couples counseling or family
therapy and the couple decides to dissolve their relationship,
the Counselor will not testify on either party's behalf. If one
or both of the parties were seen for individual counseling, then
Counselor will not willingly release records of those individual
sessions so that they can be used against the other party in some
type of legal proceeding. Shelley Tedder is unable to provide
testimony and/or make recommendations regarding where a child
should reside if parents decide to separate or divorce. By both
parties signing this agreement, they understand and agree to
these policies. Shelley Tedder will not file insurance claims for
marital/couples counseling sessions and the couple seeking
counseling services will be responsibile for paying the full fee
at time of service.
FEES,
BILLING, AND PAYMENT POLICY
TIME DEVOTED BY COUNSELOR
It is anticipated that the counselor will spend approximately 55
minutes in providing the services described under this Agreement.
The actual length of time provided may vary from week to week or
month to month, depending upon the progress of the particular
treatment plan developed pursuant to this Agreement. Initial
evaluation sessions may last longer, but will not exceed 75
minutes. If the session goes over the allotted time, then
additional fees may be assessed in the amount of $10 per every 5
minutes.
LOCATION WHERE SERVICES WILL BE RENDERED
Counseling services will be preformed at 3020 Broadmoor Lane
Suite 200, Flower Mound, TX 75022. Shelley Tedder subleases space
located at the address mentioned and maintains an independent
practice separate from Living Perspective Counseling (3020
Broadmoor Lane suite 200, Flower Mound, TX). In addition,
services may be made via telephone conferences, email, or video
chat with the client and/or collateral with active releases of
information on file. Please review confidentiality section
detailing limits of confidentiality should phone, text, email, or
video chat be utilized as confidentiality cannot be guaranteed by
counselor.
PAYMENT TO COUNSELOR/FEES FOR SERVICE
Self Pay rates:
* $200 for Couples/Family session (60 minute session)
- $150 for Individual session (60 minute session)
- $25 per 15 minute segments for phone calls
- $15 per email taking more than 15 minute read/reply
- $150 No show rate (appointments not cancelled/no notice given)
for individual sessions
- $200 No show rate (appointments not cancelled/no notice given)
for couple/family sessions
- $75 Late cancel fee (within 24 hours of scheduled
appointment)
- $20 Administrative fee PLUS $.30 per page for copies of
records
The client understands that he/she is financially responsible for
payment to Shelley Tedder. Payment is due at the time service is
rendered. Please notify Shelley Tedder if any problems arise
during the course of therapy regarding your ability to make
timely payments. If your account is overdue and there is no
written agreement on a payment plan, appointments may not be
rescheduled and Shelley Tedder can use legal or other means
(courts, collection agencies, etc.) to obtain payment.
The above rates reflect what you should expect for your health
care needs for an item or service. Any unknown or unexpected
costs that may arise will be discussed with you.
It is this practices policy to have a current and active credit
card on file authorizing payments for late cancellations, no shows,
phone call, and/or email charges. Notice will be provided as to the
charges incurred and amount being billed to the credit card. It is
your responsibility to notify counselor if you would like to make
other payment arrangements. A Credit Card Authorization form will
be presented during the initial session. If you do not wish to have
your credit card on file, any outstanding fees will require payment
prior to scheduling an appointment.
PAYMENT OPTIONS
Cash, Check, or Credit card payments are accepted.
All checks must be addressed to Shelley Tedder or Shelley Tedder
Counseling. If a check is returned to Shelley Tedder by the
processing bank and Client's account is noted as having
insufficient funds (NSF), or for whatever reason the check cannot
be paid in full, Client will be responsible for any and all service
and/or processing fees associated with said check. Further, Shelley
Tedder will assess an additional thirty dollar ($30.00) service
charge to the Client's account in order to cover the NSF fee that
the bank levees on Ms. Tedder's account. Checks that are not taken
care of within thirty (30) days may be sent to a collection agency
or referred to the authorities. In the case that a 3rd party is
contacted regarding the NSF, Client will not hold the Counselor
liable for any confidentiality that may be broken in the process of
handling the NSF. Client will also not initiate a lawsuit as
retribution because the Counselor had to seek legal action against
the Client due to Client's breaking of the contract. The balance
will have to be paid off either by cash, money order, or credit
card (additional fee for credit cards applies). Client will not be
able to pay by check. Client understands that writing a** NSF check
is against the law** and the Counselor has the option to file
charges with the proper law enforcement agency should it not be
paid
Client understands that if he/she pays by check that Shelley Tedder
Counseling cannot guarantee confidentiality when a third party
(bank personnel) is processing the checks. The same limitations
apply to the use and processing of credit card transactions.
Shelley Tedder Counseling uses Square to process credit card
transactions.
CANCELLATION POLICY
Shelley Tedder requires 24 hour notice for rescheduling and/or
canceling of appointments. It is the client's responsibility to
contact the counselor by phone or email to leave notice of the
cancellation. These methods provide time stamps documenting the
time of contact. Appointments that are cancelled within 10
hours of the session are considered late cancellations. Failure
to give proper advance notice will result in a late cancellation
fee of $75 for the first occurrence . If client has more than 2
late cancellations, the full fee for session will be charged for
the 3rd late cancellation. If client fails to give notice and
does not show for the scheduled appointment, the full fee for the
missed appointment will be charged. Insurance does not reimburse
for missed appointments. It is the responsibility of the client
to pay for missed or late cancelled appointments. Barriers to
keeping appointments and the impact on the therapeutic process
will be addressed in session. If the client has missed 2
consecutive appointments, Shelley Tedder will discuss terminating
services and provide appropriate referrals.
SUBMISSION OF IN/OUT OF NETWORK CLAIMS
If the Client is submitting claims to his/her insurance company
for out-of-network reimbursement, then Counselor will provide an
itemized invoice with dates, service codes, costs, and diagnoses
to the Client on a monthly basis. Counselor will not file
out-of-network claims. Clients using their out-of-network
benefits understand that they have to pay for the session in full
at the time of service and then get reimbursed by their insurance
company at a later date once the Client has filed the paperwork.
Shelley Tedder is a Blue Cross Blue Shield provider. Clients
using BCBSTX will be required to pay their copay/coinsurance
amount at time of service. Ms. Tedder will submit claims on
client's behalf for the remaining balance for services
rendered.
The Client understands that some diagnoses and types of
counseling may not be covered by their insurance policy and that
Counselor cannot falsely diagnose a Client in order to have a
claim paid. It is ultimately the Client's responsibility to know
whether or not their policy covers Serious Mental Illnesses (SMI
can include Depression, Bipolar, Schizophrenia) and/or marital,
family, or group therapy. Shelley Tedder does not file insurance
claims for marital/couples counseling.
Shelley Tedder has no control over, or knowledge of, what
insurance companies do with the information she submits or who
has access to this information. You must be aware that submitting
a mental health invoice for reimbursement carries a certain
amount of risk to confidentiality, privacy or to future capacity
to obtain health or life insurance or even a job. The risk stems
from the fact that mental health information is likely to be
entered into big insurance companies' computers and is likely to
be reported to the National Medical Data Bank. Accessibility to
companies' computers or to the National Medical Data Bank
database is always in question as computers are inherently
vulnerable to hacking and unauthorized access. Medical data
has also been reported to have been legally accessed by law
enforcement and other agencies, which also puts you in a
vulnerable position.
COURT APPEARANCES, LETTERS, AND FEES
For court appearances where Counselor is subpoenaed by the
Client's Lawyer or is to appear on behalf of the Client, the
charge will be two hundred dollars ($200) per hour
to be present with them from the time that the Counselor leaves
the office, regardless of whether or not the Counselor is
testifying. If it is deemed necessary that a lawyer should be
present with the Counselor, then an additional fee of two hundred
and fifty dollars ($250) an hour will be assessed. A fee of
two hundred dollars ($200) per hour for testimony
preparation will also be charged to the Client. The fee for the
Counselor to give a deposition will be two hundred dollars
($200) an hour and if deemed necessary a lawyer will be
present with the counselor at a additional rate of two hundred
and fifty dollars ($250) an hour. The time assessed will
start from the time the Counselor leaves the office. The Client
is responsible for any parking costs incurred by the Counselor,
and/or lawyer. The Client will pay a mileage fee of $0.65 per
mile from the Counselor's office to the deposition or
courtroom site. Adequate notice of at least seven
(7) business days must be given to the Counselor prior to
court or deposition appearance. If Counselor must clear his/her
schedule in case he/she may be called to testify, then the
Counselor will assess a retainer fee of seven hundred dollars
($700) for that day. Letters to the court will be
assessed a fee of twenty five dollars ($25) per letter.
See PHOTOCOPIES OF THE CLIENT'S RECORD for additional fees.
Counselor will submit an itemized statement/invoice setting forth
the time spent and services rendered by the Counselor, and Client
will pay Shelley Tedder Counseling the amount(s) due as indicated
by statements submitted by Counselor to the Client at the time
services are rendered. In the event of a court appearance
charge, an itemized statement will be submitted to the Client
with payment being due within five (5) business
days of the receipt of the statement. Further
appointments will not be scheduled until the balance is
paid off. Overdue balances may result in a collection agency
being contacted.
PHOTOCOPIES OF THE CLIENT'S RECORDS
A written request is required for copies of records. A fee will be
required for time spent preparing the record ($20 service fee plus
$.30 per page). If the records are subpoenaed, then whoever issued
the subpoena will pay for the cost of photocopying. The fee will
not apply to photocopies send to another mental health or medical
professional, such as a family doctor, psychiatrist, or
neurologist. Copies of records will require proof of identity by
the client or client's legal guardian upon pick up. Only in certain
circumstances will the records be mailed, then a fee will be
assessed for cost of mailing the records using certified mail with
return receipt.
Legal/Procedural
Policies:
COMPLAINTS against Ms. Tedder can be filed through the Texas
Behavioral Health Executive Council at 1-800-821-3205. For more
information:https://www.bhec.texas.gov/discipline-and-complaints/index.html
Texash Behavioral Health Executive Council
333 Guadalupe St. Ste 3-900
Austin, TX 78701
512-305-7700
1-800-821-3205
Insurance Complaints. If you have a complaint about your
insurance company, you can contact the Texas Insurance Commission
at: 800-252-3439 or 800-628-8574 FAX: 512-475-1771
www.tdi.state.tx.us/consumer/index.html** .
HIPAA Complaints: Health & Human Services Office of
Civil Rights below is directly from:
http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
Good Faith Estimate Disputes:www.cms.gov/nosurprises or call HHS
at 800-985-3059
If you believe that a covered entity or business associate
violated your (or someone else's) health information privacy
rights or committed another violation of the Privacy, Security or
Breach Notification Rules, you may file a complaint with OCR. OCR
can investigate complaints against covered entities and their
business associates.
**COVERED ENTITIES and BUSINESS ASSOCIATES** - A covered entity
is a health plan, health care clearinghouse, and any health care
provider that conducts certain health care transactions
electronically. A business associate is a person or entity that
performs functions on behalf of, or provides services to, a
covered entity that involve access to protected health
information. To file a complaint through their site:**
https://ocrportal.hhs.gov/ocr/index.html
Mental Health Record
Only Shelley Tedder or one of her designees are allowed to
physically handle the Client's record. In the matter of a legal
action, photocopies of the record will be sent to the necessary
parties, but not the original record. Per the LPC Board Rules of
December 2013, the mental health record is to be kept for 5 years
before it is destroyed. If the client is a minor, then the record
is kept until they are 18 and then 5 years after that time. The
keeper of records is Shelley Tedder Counseling. If Ms. Tedder
should become incapacitated, then the records will be placed in
the charge of Scott Tedder or a to be named law firm.
Per Texas Health & Safety Code 611.008, written record
requests must be acknowledged within 15 days of confirmed receipt
of said request.
Incapacity of Counselor
In the event that the Counselor becomes severely ill or deceased,
counseling records will be in the care of her appointed
custodian, Scott Tedder. If the appointed custodian should become
incapacitated or pass, then Kyle Tedder, will become the
temporary custodian of the records until a law firm is hired to
notify clients of the situation and how they may obtain their
records. If the Client needs to obtain copies of his/her records,
Client will need to contact Scott Tedder (ph.469-404-8725), and a
Release of Information will be signed before any information will
be released.
Legal Actions
Client has agreed to hold Shelley Tedder or the building in which
Shelley Tedder practices harmless for any alleged or perceived
controversies, damages or claims arising out of the rendering of
services agreed upon herein. However, in the event that Client
disregards the terms of this Agreement and initiates legal action
against Shelley Tedder for whatever reason, and Shelley Tedder
must testify in defense of or otherwise defend themselves,
confidentiality of information revealed by Client at any time
cannot be assumed. It is understood that the Counselor will offer
whatever information is deemed appropriate and necessary to
defend herself against any legal action initiated by the Client
or as a result of Client's actions.
Pending Legal Charges or Probation of Client. If the
client has any pending legal issues, they will notify the
Counselor. If the Client is on any type of probation (State or
Federal), a Release of Information will need to be signed so the
Counselor and the Probation Officer may communicate.
Therapeutic Approach. The Counselor's therapeutic style
may be discussed during the initial contact with the Counselor or
during the Intake session. Client is to let the Counselor know if
there are any issues that he/she does not wish to talk about.
Office Hours: Monday,Tuesday, Wednesday & Thursday.
E-mails and Phone calls received after 4:00 pm may not be
returned until the next business day.
Honesty. Client agrees to provide truthful information to
the Counselor during the session. If Client falsifies
information, then the Counselor will not be held liable for
whatever consequences that may arise as a result of the Client's
misinformation, falsification, or withholding of information.
Counselor holds the right to terminate services with the Client
if the Client falsifies information or is non-compliant with
treatment recommendations.
Summary of Client Responsibilities:
As a client, you agree:
1. To keep regular appointments and actively participate in your
treatment. If client has not cancelled at least 24 hours in
advance, client authorizes credit card on file to be charged the
late cancel fee. Client will pay agreed upon fees upon evaluation
and treatment at the time services are rendered or make
arrangements to do so.
2. To attempt any therapeutic assignments you agree to
perform.
3. To make a commitment to living and using counseling services
and community resources to solve difficulties. You agree to
disclose to your clinician whenever you feel in crisis and/or
suicidal, to work with them to come up with a crisis plan, and to
give your clinician discretion regarding needed disclosures in a
crisis situation.
4. To not come to counseling under the influence of alcohol or
other drugs. If you appear intoxicated, at your clinician's
request, you agree to refrain from driving yourself. Failure to
do so would require a DUI report.
5. To never bring a weapon of any sort to this counseling
center.
6. To ask your clinician questions right away if you are
uncertain about your evaluation, therapeutic process or any
policy.
Consent for Counseling Services:
Client hereby employs and authorizes Shelley Tedder to perform
the above services in accordance with the terms and conditions
set forth in this Agreement. Client understands and acknowledges
that he/she willingly and voluntarily enters into this agreement.
Client understands that these services may be terminated at any
time by either party, providing a notice is given.
Client understands, acknowledges, and agrees that participating
in the counseling process pursuant to this Agreement entails
certain risks, and no promises or guarantees of success or of any
particular results are given or implied hereunder. At the time
that services provided under this Agreement are terminated by
either party, Client understands and agrees that Client releases,
holds harmless, and forever discharges Shelley Tedder, Shelley
Tedder's heirs, executors, administrators, successors, and
assigns of and from all actions, suits, controversies, damages,
claims and demands whatsoever at law or in equity arising out of
the rendering of the services agreed upon herein.
If the client is a minor, under the age of 18, the legal guardian
agrees to the terms of this contract on behalf of the child. The
person who is over the age of 18 who is signing said contract on
behalf of the client attests to the fact that they have the legal
right to authorize treatment of said client, and that if the
guardian falsifies any information concerning his/her legal
status as guardian that he/she will not hold Shelley Tedder
liable for services that were rendered during the time where
Shelley Tedder was led to believe that the guardian had the legal
right to sign this document. If any legal action results from the
other guardian suing Shelley Tedder for not being informed of the
counseling, then Shelley Tedder will hold the guardian who
falsified information responsible for all legal costs that are
incurred by Shelley Tedder in order to defend him/herself in
court against the legal guardian.
It is this office's policy, and required by Texas State Law,
to have a copy of the most recent divorce decree/guardianship
documents on file. It is also our policy to try to involve
both parents of the minor receiving services in the therapeutic
process. A copy of the court documents must be provided before
services can be rendered. Please be able to provide name and
contact information of the other parent if they are not present
during the initial visit.
A valid identification is required for services to be
rendered.
Terms of Agreement. This agreement will begin on date of
intake/first session and will end when two weeks notice is given,
if not sooner terminated as provided herein by Counselor or
Client.
By signing below, I am indicating that I have read this document,
understand my rights as a client, and accept the responsibility
as stated. I have received copies of the Notice of Privacy Policy
and all questions regarding these policies and practices have
been answered to my satisfaction.
Date document created/revised: 04/06/16 ; 05/17/16; 09/11/18;
01/01/19; 3/21/22;8/21/23
