SLT Therapy, PLLC — New Patient Forms

Intake

Client information

Referral

Family information

Insured information

Emergency contact

List the people this office may contact in an emergency. Anyone listed may receive information that would otherwise be confidential by law. By listing a name below, you give this office permission to contact that person and provide necessary information about you in an emergency.

Office policies and procedures

Information about our counseling relationship, the procedures involved, and your consent to treatment.

Length of session: 50–60 minutes

Cost of session: $190.00

Confidentiality: Your privilege of confidentiality will be kept as stipulated by law. See the attached Confidentiality form for further detail.

Payment: The client is financially responsible for payment of fees, which are collected at the time of service. See the attached Patient Information Regarding Professional Fees form for further detail.

Cancellations: Your time is reserved for you. Any appointment not cancelled twenty-four (24) hours in advance, by phone, will be billed in full.

Consent: By seeing Samantha Ter Heege, MA, LPC, CART, I understand that I and/or my minor child are giving fully informed consent to enter into a psychotherapy relationship.

You are encouraged to raise any questions or concerns you may have.

Informed consent for psychotherapy agreement

SLT Therapy, PLLC recognizes that it may not be easy to seek help from a mental health professional. We hope that with our help you will be better able to understand your situation and feelings, and move toward resolving your difficulties. The therapist will strive to help you grow toward greater health and wholeness by providing counseling services within a biopsychosocial, cognitive-behavioral perspective. Our therapists work within the context of each individual's beliefs, and no attempt is made to impose a personal theology.

Therapist

The therapist is a licensed professional engaged in providing mental health care services to clients directly through SLT Therapy, PLLC. The therapist has discussed with me the various aspects of psychotherapy, including the evaluation and diagnostic formulation and the method of treatment. The nature of the treatment has been described, including its extent, possible side effects, and possible alternative forms of treatment. You may withdraw from treatment at any time, but please discuss this with your therapist.

Appointments and cancellations

Appointments are made by calling 281-784-3277, Monday through Friday between 7:00 am and 5:00 pm. Please call to cancel or reschedule at least 24 hours in advance, or you will be charged for the missed appointment. Third-party payments will not usually cover or reimburse you for missed appointments.

Number and length of sessions

The number of sessions needed depends on many factors and will be discussed by the therapist. Session length also varies depending on several factors, and the therapist will discuss this with you.

Relationship

Your relationship with the therapist is a professional and therapeutic one. To preserve it, the therapist cannot have any other type of relationship with you. Personal or business relationships undermine the effectiveness of the therapeutic relationship. The therapist cares about helping you but is not in a position to be your friend or to have a social and personal relationship with you. Gifts, bartering, and trading services are not appropriate and should not be shared between you and the therapist.

Goals, purposes, and techniques of therapy

There may be multiple interventions that effectively treat the problems you are experiencing. It is important to discuss any questions you have about the recommended treatment and to have input into setting the goals of your therapy. As therapy progresses, these may change.

Confidentiality

Discussions between a therapist and a client are confidential. No information will be released without the client's written consent unless mandated by law. Possible exceptions include, but are not limited to: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is at issue; situations where the therapist has a duty to disclose, or where in the therapist's judgment it is necessary to warn, notify, or disclose; fee disputes between therapist and client; a negligence suit brought by the client against the therapist; or the filing of a complaint with a licensing board or other state or federal regulatory authority. If you have questions regarding confidentiality, bring them to the therapist's attention when you discuss this matter further.

By signing the receipt form for the Informed Consent and Privacy Practices, you consent to the therapist sharing confidential information with all persons mandated by law, with the agency that referred you, and with the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services. You also release and hold harmless the therapist from any departure from your right of confidentiality that may result.

Duty to warn

If the therapist reasonably believes that the client is a danger, physically or emotionally, to themselves or another person, consent is given for the therapist to warn the person in danger and to contact any person in a position to prevent harm, including law enforcement and medical personnel. This authorization expires upon the termination of therapy.

By signing the Informed Consent and Privacy Practices forms, you acknowledge that you have the right to revoke this authorization in writing at any time, to the extent the therapist has not taken action in reliance on it. You further acknowledge that even if you revoke it, use and disclosure of your protected health information could still be permitted by law as indicated in the Notice of Privacy Practices. You acknowledge that you have been advised of the potential for re-disclosure of your protected health information by authorized recipients, and that it will no longer be protected by the federal Privacy Rule. You further acknowledge that treatment was conditioned on your providing this authorization.

Risks of therapy

Therapy is the Greek word for change. Clients often learn things about themselves that they don't like. Growth often cannot occur until past issues are experienced and confronted, which can cause distressing feelings such as sadness and anxiety. The success of therapy depends on the quality of the efforts of both the therapist and the client, along with the reality that clients are responsible for the lifestyle choices and changes that may result.

Payment for services

SLT Therapy, PLLC will look to you for full payment of your account, and you are responsible for payment of all charges. I understand that I will be charged for missed appointments and cancellations with less than 24 hours notice. All cancellations should be called into the office; feel free to leave a message after hours and on weekends to avoid a late cancellation fee. Insurance will not cover charges for missed appointments or late cancellations.

I am not in-network with any insurance company and do not bill insurance. Providing your insurance information (card) and payment in full will enable me to give you a standard insurance claim form (HCFA 1500) that you may choose to file with your insurance company for any out-of-network benefits you may have, payable to you.

Court

Although it is the therapist's goal to protect the confidentiality of your records, there may be times when disclosure of your records or testimony is compelled by law. If disclosure of your records or the therapist's testimony is requested by you or required by law, you are responsible for and shall pay the costs involved.

After-hour emergencies

In an emergency, call 911 or go to the nearest emergency room.

Therapist's incapacity or death

If the therapist becomes incapacitated or dies, another therapist will need to take possession of client records. By signing the Informed Consent and Privacy Practices Receipt, you consent to another licensed mental health professional taking possession of your files and records and providing you with copies upon request, or delivering them to a therapist of your choice.

Consent to treatment

By signing the Informed Consent and Privacy Practices Receipt, you voluntarily agree to receive mental health assessment, care, treatment, or services, and you authorize the therapist to provide such care as is considered necessary and advisable. Signing indicates that you understand and agree that you will participate in planning your care and that you may stop such care at any time. You also acknowledge that you have read and understood all the terms and information contained here, and that ample opportunity has been offered to ask questions and seek clarification of anything that remains unclear.

Contact information

By signing the Informed Consent and Privacy Practices Receipt, you consent to SLT Therapy, PLLC communicating with you by mail, email, and phone at the address and phone numbers provided at the initial appointment, and you agree to advise SLT Therapy, PLLC immediately of any change. You agree to notify SLT Therapy, PLLC if you need to opt out of any form of communication.

Notice of SLT Therapy, PLLC privacy policies

This notice tells you how we make use of your health information at SLT Therapy, PLLC, how we might disclose it to others, and how you can get access to it. Please review it carefully and feel free to ask for clarification about anything you do not understand. The privacy of your health information is very important to us and we want to do everything possible to protect it.

We have a legal responsibility under the laws of the United States and the state of Texas to keep your health information private. Part of that responsibility is to give you this notice; another part is to follow the practices described in it. This notice took effect on September 17, 2018 and remains in effect until we replace it. We have the right to change any of these privacy practices as long as the changes are permitted or required by law.

Any changes in our privacy practices will affect how we protect the privacy of your health information. This includes health information we receive about you or create here at SLT Therapy, PLLC, and it could also affect how we protect health information we held before the changes. When we make such changes, we will also change this notice and give you a copy of the new one.

When you have finished reading this notice, you may request a copy at no charge, now or at any time in the future. If you have questions or concerns about this document, please ask us for assistance, which we provide at no charge.

How we may use or disclose your health information

1. To your physician or other healthcare provider who is also treating you.
2. To anyone on our staff involved in your treatment program.
3. To any person required by federal, state, or local laws to have lawful access to your treatment program.
4. To receive payment from a third-party payer for services we provide for you.
5. To anyone you give us written authorization to have your health information, for any reason you want. You may revoke this authorization in writing at any time; a revocation affects only your health information from that point on.
6. To a family member, a person responsible for your care, or your personal representative in an emergency. If you are present in such a case, we will give you an opportunity to object. If you object, are not present, or are incapable of responding, we may use our professional judgment, in light of the nature of the emergency, to use or disclose your health information in your best interest at that time. In doing so, we will only use or disclose the aspects of your health information necessary to respond to the emergency.
7. To the appropriate state agency if we suspect the neglect or abuse of a minor or adult. If, in our professional judgment, we believe that a patient is threatening serious harm to another, we are required to take protective action, which may include notifying the police or seeking the client's hospitalization. If a client threatens to harm themselves, we may be required to seek hospitalization.

We will not use your health information in any of our marketing, development, public relations, or related activities without your written authorization. We cannot use or disclose your health information in any way other than those described in this notice unless you give us written permission.

As a client of SLT Therapy, PLLC, you have these rights

• With limited exceptions, you can make a written request to inspect the health information we maintain for our use.
• You can ask us for photocopies of that information. There is a $25.00 charge for copies made here. If you need copies due to a third-party request, we charge $25.00 for the first 20 pages, then $0.50 for each additional page.
• You have a right to a copy of this notice at no charge.
• You can make a written request that we communicate with you about your health information by alternative means or at an alternative location — for example, contacting you at a phone number other than your residence. Your written request must specify the alternative means and location.
• You can make a written request that we place other restrictions on the ways we use or disclose your health information. We may deny any or all requested restrictions. If we agree to them, we will abide by them in all situations except those that, in our professional judgment, constitute an emergency.
• You can make a written request that we amend the information described above. If we approve your written amendment, we will change our records accordingly and notify anyone else who may have received the information, plus anyone else of your choosing. If we deny your amendment, you can place a written statement in our records disagreeing with the denial.
• You may make a written request that we provide a list of occasions where we or our business associates disclosed your health information for purposes other than treatment, payment, or SLT Therapy, PLLC operations. This can go back as far as six years, but not before September 9, 2012. If you request this accounting more than once in a 12-month period, we may charge a fee based on our actual costs of tabulating the disclosures.
• If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your rights in this notice, you may complain to us in writing: Samantha Ter Heege, MA, LPC, CART, sterheege@slttherapy.com, 281-784-3277. You may also submit a written complaint to the United States Department of Health and Human Services; we will provide that address upon written request.

Receipt

acknowledge that I have reviewed and received signed copies of the Informed Consent and Privacy Practices forms from SLT Therapy, PLLC.

Confidentiality

Please read carefully.

Generally speaking, communications between a patient and a mental health provider are confidential and may not be disclosed without your consent, or as otherwise provided by law.

There are exceptions to that general rule which would require the provider to report their concerns without the consent of the patient. These occasions include, but are not limited to, the following:

• Belief that child abuse has occurred or may occur
• Belief that an elderly or mentally handicapped person has been or may be abused
• Reports by a patient of possible sexual abuse or exploitation by a previous therapist
• Personal danger to self or an identifiable victim
• Testimony required by a judge
• Information provided to parents if the client is a minor
• Consultation with supervising professionals

Special rules apply to minors: by law, a parent has the right to the medical record of a child unless that right has been limited by court action. Parents may agree that during the course of treatment given to a minor child they will waive the right to the child's medical record. Such a waiver is often helpful for useful clinical work with a minor.

Additionally, advice may be elicited from professional peers regarding your case without revealing your identity.

If you have any questions, or would like additional information, please feel free to ask.

Acknowledgement by patient

Waiver of access, for a minor client

Patient information regarding professional fees

I understand that payment is expected at the time of delivery of service. I authorize Samantha Ter Heege, MA, LPC, CART or her authorized representative to charge my credit card.

I understand that I will be charged for missed appointments and cancellations with less than 24 hours notice. All cancellations should be called into the office. Feel free to leave a message after hours and on weekends to avoid a late cancellation fee. Insurance will not cover charges for missed appointments or late cancellations.

The financial responsibility for services provided is yours, and insurance is for your reimbursement.

I am not in-network with any insurance company and do not bill insurance. Providing your insurance information (card) and payment in full will enable me to give you a standard insurance claim form (HCFA 1500) that you may choose to file with your insurance company for any out-of-network benefits you may have, payable to you.

I understand that if I am involved in any legal action requiring testimony or deposition, Samantha Ter Heege, MA, LPC, CART will charge a fee of $300 per hour, portal to portal. This fee also covers time spent preparing for the testimony or deposition and copying any records involved. There is a three-hour minimum charge for any testimony or deposition.

Card on file

Email and texting consent

You may give permission to SLT Therapy, PLLC to communicate with you by email and text message (SMS). This form provides information about the risks of these forms of communication and how we use them. It also documents your consent to be contacted this way.

1. How we will use email and text messaging

We use these methods to communicate only about non-sensitive and non-urgent issues. All communications to or from you may become part of your medical record, and you have the same right of access to them as to the rest of your record. We will not disclose your emails or text messages to researchers or others unless allowed by state or federal law. Please refer to our Notice of Privacy Practices for permitted uses of your health information and your rights regarding privacy matters.

2. Risks of using email and text messages

• Emails and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
• Senders can easily misaddress a message and send information to an undesired recipient.
• Backup copies may exist even after the sender or recipient has deleted their copy.
• Employers and online services have a right to inspect messages sent through their company systems.
• Messages can be intercepted, altered, forwarded, or used without authorization or detection.
• Messages can be used as evidence in court.
• Email and text messaging may not be secure, so it is possible that a third party may breach the confidentiality of such communications.

3. Conditions for the use of email and text messages

SLT Therapy, PLLC staff cannot guarantee, but will use reasonable means to maintain, the security and confidentiality of email and text information sent and received. You must acknowledge and consent to the following conditions:

• In a medical emergency, do not use email — call 911. Do not email about urgent problems. If you have an urgent problem during regular business hours, call the office. Urgent messages or needs should be relayed by regular telephone communication, and may include text messages.
• Emails should not be time-sensitive. While we try to respond to email daily, we cannot guarantee that any particular email will be read and answered within any particular period. If you have not heard back within three days, call the office to confirm we received it.
• You should speak with your therapist about complex or sensitive situations rather than send email or text messages about them.
• Email and text messages may be filed electronically into your medical record.
• Clinical staff will not forward your identifiable messages to outside parties without your written consent, except as authorized by law.
• Use your best judgment when considering email or text for sensitive information. Clinical staff are not responsible for the content of messages.
• SLT Therapy, PLLC and its staff are not liable for breaches of confidentiality caused by you or any third party.
• It is your responsibility to follow up with your therapist, if warranted.

4. Withdrawal of consent

I understand that I may revoke this consent at any time by advising SLT Therapy, PLLC in writing. My revocation will not affect my ability to obtain future health care, nor will it cause the loss of any benefits to which I am otherwise entitled.

5. Client acknowledgement and agreement

Permission to obtain services via Skype / FaceTime

This information is entirely confidential.

You have requested to receive services via Skype or FaceTime. These are free, downloadable internet applications that allow users to transmit video over the internet via webcam and to share various kinds of files. To participate, please provide the permission and information below.

We take precautions in using web cameras in an attempt to protect your privacy. However, since Skype and FaceTime are public services, be aware that sending information over the internet carries the risk of personal information being accidentally disclosed to other people. For this reason, we need your permission to provide services this way.

Credit card authorization

I have provided SLT Therapy, PLLC with my credit card number and authorize them to keep my signature on file and to charge my credit card account for all balances, all missed appointments, and all insurance payments paid directly to me that were due this office. I understand that this form is valid unless I cancel the authorization through written notice to this office.

Assignment of benefits

I hereby authorize payment to SLT Therapy, PLLC for the medical benefits otherwise payable to me, not to exceed the therapist's charge. I understand that I am financially responsible for charges not covered by this authorization.

I hereby authorize SLT Therapy, PLLC to release to my insurance company any clinical information required to assist with the filing of my insurance claim. This may include clinical options, diagnosis, treatment plan, and history information.

I further agree not to hold Samantha Ter Heege, MA, LPC, CART or her associates liable for the disclosure of such clinical information, as it is at my request that it be provided. I also understand that my insurance company will be requesting details and specific historical information, and I hereby authorize release of such.

Benefit and authorization is a determination based on medical necessity and is not a guarantee of claim payment. Payment determination is made at the time a claim is received and is based on eligibility, plan limits, plan exclusions, and overall plan language.

All insurance benefit verifications are subject to final payment from your insurance company and are not the responsibility of this office.

Authorization to use / disclose information

to disclose or release one to the other the following information from my records:

For the purpose of treatment, management, and/or supervision of psychological and/or medical conditions, I hereby waive my right to the privileges of confidentiality as specified above for a period of one year after termination of treatment, management, or supervision, unless expressly revoked earlier in writing.