PRACTICE POLICIES APPOINTMENTS AND CANCELLATIONS Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours or "No show" happens during your scheduled appointment. Cancellations and "No Show" session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time. BILLING Our hourly rate for providing psychotherapy is $60 per hour (50 minutes). This will be billed to your credit card on file. Fees may be reduced or waived on a case-by-case basis. If a client misses (3) "No Show" appointments consecutively the client will be terminated from therapy services due to lack of engagement in therapy services. 

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911, Regional Crisis Line for 24/7 crisis support (1-877-266-1818) or any local emergency room.

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.

ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use the methods of communication discussed in a therapeutic content and/or request assistance for emergencies.

MINORS If you are under the age of 18, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. Parents/guardians must inform us of all guardians who have medical decision-making rights.

HEALTH STATEMENT It is important that you are aware that we offer telehealth counseling making your presence in-office optional. Should you choose to attend in-office appointments, you are agreeing to do so only when feeling well and in accordance with the Control Disease Center (CDC).  In addition, you are doing so at your own risk and Sapphire Therapy & Wellness or its contractors are not liable for any communicable health conditions that may or may not be contracted in attending in-office appointments or in the transportation to/from these appointments. Note that our contracted providers are taking all reasonable precautions with regard to sanitization as well and may cancel appointments at any time citing health concerns.

COMPLETION OF SERVICES 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. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I 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, I 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. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. YOU WILL BE ASKED TO SIGN A DISCLOSURE RECEIPT DURING YOUR FIRST APPOINTMENT.

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 person 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 Jennifer Anderson Sapphire Therapy & Wellness Parrish, FL 34219 (941) 776-9651.

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 Jennifer Anderson Sapphire Therapy & Wellness Parrish, FL 34219 (941) 776-9651; 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.

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. Jennifer Anderson Sapphire Therapy & Wellness  Parrish, FL (941) 766-9651.

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. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on September 20, 2013 Acknowledgement of Receipt of Privacy Notice Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. YOU WILL BE ASKED TO SIGN A DISCLOSURE RECEIPT IN YOUR FIRST APPOINTMENT.

Informed Consent for Sapphire Therapy and Wellness Services

Please read this Informed Consent Statement before beginning your session with your therapist.  Please feel free to discuss any questions or concerns you have about this statement with your therapist before signing this document.  Once you have signed the document a copy will be provided for you.

Theoretical Orientation

I am educated, trained, and equipped in serving multiple populations, ages, sex orientation, gender, and disorders using different psychological theories that meet the needs of that individual.  I practice to identify and challenge the client's maladaptive thinking and behaviors that contribute to the problem.  The therapy sessions will be structured to aid the client in making incremental progress towards the client's goals.  Homework may be assignments to be completed at home that will be related to his or her goals between sessions. Treatment plans are assigned to keep the client on track with goals; both short-term and long-term goals.  The therapy techniques used during therapy will aim to benefit the client to make changes with unwanted or destructive thoughts, feelings, and behaviors. Those techniques may include mindfulness; breathing and relaxing exercises; exposure; role playing; journaling; and practicing new coping skills during therapy sessions. 

Eligibility and Services Limits

Sapphire Therapy & Wellness is a private practice that provides services to both children and adults.  The services are provided by fees of self-pay only. Sapphire Therapy & Wellness does not take in/out of network insurance at this time. The services provided are based and determined by the individual's needs and goals along with resources from the most recent research that is available to fit the client's symptoms and impairments.  If the therapist is unable to provide services for the individual, the individual will be referred to other outside resources.

Confidentiality

Sapphire Therapy & Wellness adheres to Federal and State laws and ethical standards; all client information is held in confidence unless written permission is given to release any of the client information. To provide superior and effective services, the therapist may ask the client to sign an information of release to consult with outside resources; such as medical staff (Physicians and Psychiatrists). Federal and State laws require that health and counseling professionals to report certain situations. These situations include danger to self or a danger to others, specific harm to specific person, past or current harm to a child, elder, or adult abuse. A confidential counseling record is maintained by the therapist.  The client records could be released to the courts when mandated by the court and by the client's signature.  Please note: depending on the mandate of the order from the court, the therapist will discuss with the client and the courts what is appropriate to release or if any records will be released to the courts. The therapist will discuss in more detail depending on the situation with the client when it refers to a mandated court release of records.

Benefits and Risks

There are benefits and risks that may occur in counseling sessions. The benefits from counseling may include improving the client's life goals and needs that will lead to improvement in developmental life skills; improve interpersonal relationships; and an overall improvement in the client's lifestyle.  Counseling risks that may involve unpleasant events that could bring on strong feelings. The mission and goals are to provide effective and high-quality counseling with the highest ethical standards.

Emergencies

For after hour emergencies please contact National Suicide Prevention Lifeline (800) 273-8255.  Florida Abuse Registry Hotline (800) 96Abuse (2873).  State of Florida Domestic Violence Hotline (800) 500-1119.

Appointments

If you are unable to keep the therapy appointment, please contact the therapist at jennifer@sapphiretherapywellness.com as soon as possible. Cancellations, no-show, and rescheduled sessions will be subject to a fee of $100 unless planned 24 hours in advance.  If the client cancels three or more appointments; the client will be referred to another counseling agency.  If the therapist is unable to keep the appointment the therapist will attempt to contact the client to reschedule the appointment as soon as possible.  

SELF-PAY FEE SCHEDULE:

THE SESSION FEE MUST BE MADE PRIOR TO SESSION by adding a credit card to the client file.

First Session: 

"NO SHOW" (After 15 minutes from appointment time) and "LATE CANCELLED" (Less than 24 hours) will be charged the fee of $100.00 to the credit card on file.

INDIVIDUAL THERAPY

o   $120.00 PER 50 MINUTE SESSION 

o   $50.00 PER 30 MINUTE SESSION 

"NO SHOW" (After 15 minutes from appointment time) and "LATE CANCELLED" (Less than 24 hours) will be charged the full amount of $100.00 for the session fee to credit card on file.

IN-HOME THERAPY

     o  $120.00 PER 50 MINUTE SESSION 

     o  $30.00 FEE TRAVEL FEE FOR TRAVEL TIME OUTSIDE OF PARRISH AREA

"NO SHOW" (After 15 minutes from appointment time) and "LATE CANCELLED" (Less than 24 hours) will be charged the full amount of $100.00 for the session fee to credit card on file.

PARENT COACHING

   o  $100.00 session via Telehealth Video/Phone up to 60 minutes

"NO SHOW" (After 15 minutes from appointment time) and "LATE CANCELLED" (Less than 24 hours) will be charged the full amount of $100.00 for the session fee to credit card on file.

DBT Skills Training

   o  $80.00 session via Telehealth Video up to 60 minutes

"NO SHOW" (After 15 minutes from appointment time) and "LATE CANCELLED" (Less than 24 hours) will be charged the full amount of $80.00 for the session fee to credit card on file.

BILLING HEALTH INSURANCE:

Intake sessions that provide assessment/psychotherapy are billed at $240.00 per hour (60 minutes). Our hourly rate for providing psychotherapy is $220 per hour (53+ minutes).  This will be billed to your insurance. You will be responsible to pay all co-pays and fees not covered by insurance.  If your insurance plan has a deductible, co-pay, or co-insurance, you agree to provide a payment method and consent to enrolling in autopay.

Insurance Information

The following terms can be helpful for you to understand your insurance plans and coverage. It is up to you to know your plans and coverages. You can reach out to your insurance provider via the number on the back of your card.

â- Deductible: The amount that needs to be paid out of pocket before insurance will

pay

â- Co-Pay: A set amount that is paid out of pocket per visit

â- Co-insurance: A percentage of the rate that needs to be paid out of pocket

â- Out-of-network: Billing an insurance plan wherein there is no established contract

with Sapphire Therapy & Wellness.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual  relationships, your provider or any Sapphire Therapy & Wellness staff do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Twitter, LinkedIn, etc). We 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 you meet with your provider so it can be discussed further.

ELECTRONIC COMMUNICATION

Sapphire Therapy & Wellness does not ensure the confidentiality of any form of communication through electronic media, including, but not limited to, text messages. You may send an email or make a phone call to seek information and initiate services. It is preferred to communicate via email for issues regarding scheduling or cancellations, your provider will do so. While they may try to return messages in a timely manner, they cannot

guarantee immediate response and request that you do not use these methods of

communication to discuss therapeutic content and/or request assistance for emergencies.

Consent to Counseling

I have read all the above conditions of counseling.  I agree and accept these conditions and give my consent to be counsel.  I understand that I may stop treatment at any time.

CONSENT FOR TELEHEALTH CONSULTATION/PSYCHOTHERAPY

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 CounSol Telehealth by CounSol 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 CounSol 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 CounSol 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 CounSol 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 CounSol 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 CounSol 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.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.