Client Service Agreement and Informed Consent: Therapy

This document contains important information about my 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 patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it creates an agreement between AnneMarie Olson, LCSW, Inc. (“me; “I”, “my practice”) and you (“client”). We can discuss any questions you may have when you sign them or at any time in the future.

About the Therapy Process

It is my intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to me regarding the specifics of your situation, I will provide recommendations to you regarding your treatment. I believe that therapists and clients are partners in the therapeutic process. You have the right to agree or disagree with my recommendations. I will also periodically provide feedback to you regarding your progress and will invite collaboration. It is important to know there are risks and benefits associated with therapy. For example, sometimes therapy brings out deep emotional issues that are difficult to process and cope with. It may appear things get worse before they get better. The goal is to address these issues in a way that will lead to improvements in your life. I am committed to providing you with support and ensuring your safety. Due to the varying nature and severity of problems and the individuality of each client, I am unable to predict the length of your therapy or to guarantee a specific outcome or result.

The stages for Treatment

  1. Intake: Assess for Immediate Concerns (risk factors and Crisis), Goodness of Fit, Management and Practice Issues, and Developing Therapeutic Framework
  2. Early Stage: Assessment, Goal Setting, Identifying Resources/Referrals
  3. Middle Stage: Goals and Interventions
  4. Final Stage: Late Stage (Prepare to cope for future, including relapse prevention and identifying supports) and Termination (Review progress and consolidation gains)

Termination of Therapy

The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea for us to plan for your termination. I will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or I determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy. If participation in services is inconsistent or if contact is not maintained, services may be terminated. If you miss more than one appointment without notice, services will be terminated. 

Business Policies

Professional Services and Fee Schedule

The following is a list of my fees for psychotherapy and other services:

  • individual, couple or family therapy or Advance Care Planning  session. 50 minutes. $160.00 
  • report or letter writing: $80 for 30 minutes; $160 for up to 1 hour. (pro rata)
  • court or deposition service*: Per 1 hour $ 500.00; full day $3000 (plus travel and administrative fees)
  • phone calls:  calls that last more than 10 minutes will be prorated my hourly fee at $160.  Please attempt to use phone calls for scheduling purposes and save consultation for session time.

Insurance

I do not bill insurance directly. Depending on your current health insurance provider or employee benefit plan, it may be possible to seek full or partial reimbursement for the cost of the session(s). Receipts for services are available upon request and may be used to seek reimbursement from your insurance. Consult with your insurance provider regarding your mental health services and out of network benefits.

Appointment Scheduling and Cancellation Policy

Your consistent attendance greatly contributes to a successful outcome. I require a 24-hour notification when cancelling or rescheduling any appointment. Any late cancelations (less than 24-hour notice) and/or “no-shows”’ will result in full fee charges to your credit card on file. If participation in services is inconsistent or if contact is not maintained, services may be terminated. If you miss more than one appointment without notice, services will be terminated. If you are late for your session, I will wait 15 minutes. I understand that things happen that can sometimes interfere with our schedules despite our best intentions. We can still have a session if you show up late, but the session must end at the previously agreed upon time to respect other clients scheduled after you. You will still be billed for the entire 50-minute session. 

In the event that I am unable to attend our scheduled appointment, I will contact you via your preferred method of communication to cancel and reschedule the session. You will be notified in advance of vacations or planned extended absences. You and I will determine a revised treatment plan prior to the absence.

Phone Calls

You are welcome to phone me in between sessions. However, I will attempt to keep those contacts brief. Should the contact be lengthy (longer than 10 minutes), you will be charged for a phone session according to the fee schedule above. As a general rule, it is my belief that important issues are better addressed within regularly scheduled sessions. Please note I am not on call, and therefore may not respond immediately.

You may leave a message for me at any time on my confidential voicemail. If you would like me to return your call, please be sure to leave your name and phone number, along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during my normal work schedule within 48 hours. 

My work schedule is below and subject to change, but will be updated on website as appropriate:

Monday: 10:00 a.m. – 7:00 p.m.
Tuesday: 6:00 p.m. – 8:00 p.m.
Wednesday: 9:00 a.m.- 6:00 p.m.

I am not available to return calls on Saturdays or Sundays.

Emergencies

I am unable to provide 24-hour crisis service. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911, or go to the nearest emergency room. As part of our agreement for working together I require two emergency contact persons that I may call in the event of an emergency.

The following national and local Marin county resources are available to assist those in crisis:

  • Buckelew 24/7 Suicide Prevention Hotline: 415-499-1100
  • National Suicide Prevention Hotline: 800-273-8255
  • Domestic Violence Helpline: 415-924-6616

Participation in Litigation

I will not voluntarily participate in any litigation, or custody dispute in which a client and another individual, or entity, are parties. I have a policy of not communicating with a client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in a legal matter unless agreed upon at the beginning of the therapeutic relationship. I will generally not provide records or testimony unless compelled to do so. Should I be subpoenaed, or ordered by a court of law, to appear as a witness in an action in which you are involved, you agree to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance according to the fees listed above.

Notice of Privacy Practices

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.

I am required by law to maintain the privacy and security of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). I must abide by the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. 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/or on my website. Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization (“Authorization”). It is your right to revoke such Authorization at any time by giving me written notice of your revocation.

Uses (within my practice) and Disclosures (outside my practice) relating to treatment, payment, or health care operations do not require your written consent. 

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 counterintelligence 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.

Certain uses and disclosures require your authorization.

  1. Psychotherapy Notes. I 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:
    1. For my use in treating you.
    2. For my use in training or supervising other mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
    3. For my use in defending myself in legal proceedings instituted by you.
    4. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
    5. Required by law, and the use or disclosure is limited to the requirements of such law.
    6. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
    7. Required by a coroner who is performing duties authorized by law.
    8. Required to help avert a serious threat to the health and safety of others.
  2. Marketing Purposes. I will not use or disclose your PHI for marketing purposes without your authorization.
  3. Sale of PHI. I will not sell your PHI.

Certain uses and disclosures require you to have the opportunity to object.

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

Your Rights Regarding Your Protected Health Information (PHI)

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 a Copy of this Notice. You have the right to get a copy of this Notice by paper or electronically.

Complaints About Privacy Practices

If you think I may have violated your privacy rights, you may file a formal complaint with me, as the Privacy Officer for my practice which I am required to retain and make available to state or federal authorities; my business address and phone number are 655 Irwin Street #1110., San Rafael, CA 94901; (415) 683-1441. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

  1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201
  2. Calling 1-877-696-6775
  3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints

I am prohibited by law from retaliating against you for filing a complaint about my privacy practices.

Minors and Confidentiality

Communications between me and clients who are minors (under the age of 18) are confidential. However, parents/legal guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, I, in my professional judgment, may discuss the treatment progress of a minor patient with the parent or caretaker.

Notice of Use of Online Therapy/Telehealth

Therapy will be conducted via Google Meet, a HIPAA compliant Video Chat Platform. Prior to our first online therapy appointment, I will send you a link invitation to our session. Please note services are not provided through Skype/facetime/etc, as they are not HIPAA compliant. In order for you to have privacy, it is important that you find a place (home, work, or another location) where you can participate in sessions without being interrupted or overheard. By signing this policy, you agree that you can secure such a location, free of other people, distractions, and interruptions, where you will have the ability to connect to the internet in order to engage in therapy sessions as scheduled.

I am only legally allowed to conduct online therapy with clients who live in states where I am a licensed provider of mental health services. At this time this only includes California, therefore if you do not legally reside in California we cannot conduct therapeutic sessions. Also, if you move out of the state of California I will be unable to continue providing online therapy services to you. 

Adding technology to the therapeutic relationship can lead to complications beyond the control of either the therapist or the client. If such technological problems (such as a lost internet connection) occur, we will continue our session by telephone. This will not change the fee schedule for the session.

Your rights with respect to telehealth

  1. You have the right to withhold or withdraw consent at any time without affecting your right to future care or treatment 
  2. The laws that protect the confidentiality of your medical information also apply to telemedicine. As such, the information disclosed by you during the course of your therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards self or others. 
  3. There are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of your psychotherapist, that: the transmission of your medical information could be disrupted or distorted by technical failures; the transmission of your medical information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons. In addition, please understand that online based services and care may not be as complete as face-to-face services. I will advise you if you would be better served by another form of therapeutic services (e.g. face-to-face services). You will be referred to a therapist who can provide such services in your area if needed. Finally, there are potential risks and benefits associated with any form of psychotherapy, and that despite your and my efforts, your condition may not improve, and in some cases may even get worse.
  4. You may benefit from telehealth, but results cannot be guaranteed or assured. 

Client Email/Texting Policy

As a general rule please do not text or email me to communicate. You will receive automated appointment reminders, but all other communication should be kept for session time or made via phone call. Please find the concerns outlined below.

Risks

The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks: 

  1. Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. 
  2. Email and text senders can easily misaddress an email or text and send the information to an undesired recipient. 
  3. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy. 
  4. Employers and on-line services have a right to inspect emails sent through their company systems. 
  5. Emails and texts can be intercepted, altered, forwarded or used without authorization or detection. 
  6. Email and texts can be used as evidence in court. 
  7. Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party. 

Conditions for Use 

I cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text information sent and received. I am not liable for improper disclosure of confidential information that is not caused by my intentional misconduct. Clients/Parents/Legal Guardians must acknowledge and consent to the following conditions: 

  1. Email and texting is not appropriate for urgent or emergency situations. I cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
  2. Email and texts should be concise. The client/parent/legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations. 
  3. I will not forward client’s/parent’s/legal guardian’s identifiable emails and/or texts without the client’s/parent’s/legal guardian’s written consent, except as authorized by law. 
  4. Clients/parents/legal guardians should not use email or texts for communication of sensitive medical information.
  5. I am not liable for breaches of confidentiality caused by the client or any third party. 
  6. It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an appointment if warranted.

Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.

Social Media Policy

This policy’s purpose is to outline how I conduct myself on social sites as a mental health professional and how you can expect me to respond to various interactions that may occur between clients and clinicians on the Internet. Confidentiality means that I cannot tell people that you are a client. You are encouraged to take your own privacy as seriously as I take my commitment of confidentiality to you.

Friending

I will not accept “friend” requests from current or former clients on their personal social networking sites (Facebook, Twitter, LinkedIn, etc.). Adding clients as “friends” on these sites can compromise your confidentiality and my 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. 

Liking/Following

You are welcome to “like” or “follow” my social media feeds and read or share articles I post; however, because social media sites are public spaces, anyone who can see our social media pages can see your post or comment. In addition, when you post, comment, or “like” a page, it will likely be published on your page as well. My primary concern is your privacy. You are welcome to use your own discretion in choosing whether to follow my practice. In order to maintain ethical boundaries, I will not follow you back.

Direct Messaging

Please do not use SMS (mobile phone text messaging), wall posting, @ replies, messaging on Social Networking sites in order to contact me. Communicating in this way could compromise your confidentiality and I may not receive your message. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. 

Search Engines

It is not a regular part of my practice to search for clients on Google or Facebook or other search engines. Due to the fact that I am a mandated reporter, extremely rare exceptions may be made during times of crisis. If a I have reason to suspect you are in danger and you have not been in touch with me via usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I resort to such means, the information will be fully documented and discussed with you during your next session. 

Business Review Sites 

You may find me on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find me on any of these sites, please know that this listing is not a request for a testimonial, rating, or endorsement from you as a client. The American Counseling Association’s Ethics Code prohibits clinicians from requesting testimonials for marketing purposes. If you are using these sites to communicate your feelings about your therapeutic experience me, the communication may not be seen by me. You have a right to express yourself on any site you wish; however, due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative. My hope is that you will bring your feelings and reactions concerning your treatment directly into the therapy process. This can be an important part of treatment, even if you decide to go elsewhere. If you do choose to write something on a business review site, please keep in mind that you may be sharing personally revealing information in a public forum. 

Location-Based Services (LBS) 

If you use location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. If you have GPS tracking enabled on your device, it is possible that others may surmise that you are a client due to regular check-ins at our office on a weekly basis. Please be aware of this risk if you are intentionally “checking in” from our office or if you have a passive LBS app enabled on your phone.

EFFECTIVE DATE OF THIS NOTICE This Notice went into effect on September 21, 2021.