Gingko Leaf Counseling utilizes text, email and telehealth communication for appointments, scheduling, confirmations, and resource sharing. The platforms utilized for email and video sessions are HIPAA protected through a third party. The above phone number listed is utilized mainly for scheduling and confirmation purposes. By signing below, you agree that if you choose to text any number associated with Gingko Leaf Counseling, personal or private information you are aware that Ginkgo Leaf Counseling cannot guarantee the confidentiality of the information sent. By signing below, you also agree that you understand that the line is not an emergency line. In the event of an emergency or immediate help is needed please call 911.

By signing this consent, you are acknowledging that you understand the purpose of text and email messages as addressed above. Your signature indicates the agreement that you take full responsibility for any information you choose to text or email.

Office Policies and Consent for Treatment
Welcome To Ginkgo Leaf Counseling. This document serves to inform you about my practice, business policies, professional services offered and potential risks and benefits of therapy. By signing this document, it represents an agreement between you and Ginkgo Leaf Counseling LLC. Please clarify any questions or concerns prior to signing this agreement.

PSYCHOLOGICAL SERVICES
It is important to define the rights and responsibilities held by me as well as the rights and responsibilities of you as the patient. It is important to understand that starting therapy will have both benefits and risks. Risk may include uncomfortable feelings and emotions including but not limited to, anger, sadness, guilt, anxiety, frustration, loneliness, and helplessness. These can occur due to the process of therapy which can require discussing various aspects of your life. The proven benefits of psychology have shown that discussing these events and utilizing evidenced based treatments can lead to a reduction of feelings of distress. Additionally, it can lead to increased feelings of satisfaction, increased self-awareness, improvements in relationships, stress management skills as well as increase in healthy communication styles. There are no guarantees about what will happen in your therapeutic process and each process is unique to the individual. To increase the benefits of therapy it is important that you are an active participant in your therapy, which requires work outside of sessions.

APPOINTMENTS
Our first session will consist of an evaluation to gather information and get to know each other. The following 2-3 sessions will focus on gaining a comprehensive understanding of your needs and wants in the therapeutic process. We will work together to define these goals and address a plan for your process in therapy.  It is important that you feel comfortable working with me as your therapist. Please take time to ask any questions and ensure you feel we are a good fit to continue to work together.  If we are not a good fit to move forward, I am happy to help provide resources for alternative options.

The initial evaluation will be about 45-60 minutes in duration. Follow up sessions will be about 53 minutes long. We will plan follow up sessions in session and you will have access to make changes online or through calling the office. Please keep in mind that your appointment time is set aside for you. If you need to cancel or reschedule, I require 24 hours' notice. If the session is missed or cancelled outside of the requested time frame there will be a $50 dollar fee. This fee will need to be paid in part or in full prior to another session being scheduled. I value your time and I ask the same in return. Please be on time for your appointments. There is a 10-minute window to be late. If you are outside of this time the session will be cancelled and the fee will apply. Please be mindful if you are late to session your session will still end on the predetermined time.

PROFESSIONAL FEES
The standard fee for an evaluation is $125.00 and follow up sessions are $105.00. Payment is required at the time of your session. If you are utilizing insurance, please sign the waiver form to allow us to access your insurance. By signing this agreement, you are stating that you understand you are responsible for anything that insurance does not cover related to your appointment. If there is refusal to pay or a debt, I reserve the right to use a collection agency or an attorney to secure payment. If there are additional requests outside of therapeutic sessions these will be discussed as they arise.

INSURANCE
Please be aware of what your insurance covers in terms of your sessions. Some insurances provide A SET NUMBER of appointments that they will cover. It is your responsibility to be aware of what is and what is not covered. If your insurance changes it is your responsibility to share this information with me as soon as coverage changes to ensure claims are filed correctly.  Insurance companies require a clinical diagnosis for claims to be processed. By signing this document, you agree that you are authorizing me to provide the insurance with a clinical diagnosis based on the content of our sessions. I am happy to go over and clarify any questions you may have about your diagnosis. Please keep in mind insurance companies can request information related to your treatment. If your insurance requires a copay. Copay is required at the time of your visit. Some insurance companies require your deductible to be met for sessions to be covered. Please be aware of this as you are responsible for any service rendered where fees have not been collected through insurance.

RECORD KEEPING
I am required to keep records related to the services I provide. Your records are maintained for the majority electronically through a HIPAA protected system. If you are requesting records to be sent to another provider, this requires a Release of Information to be signed giving me permission to release these records. You may also request records for yourself. Please be mindful that the records are written in a clinical manner which to untrained readers can lead to misinterpretation. Please consider reviewing the documentation with me prior to reading it on your own to ensure a healthy understanding of the content.

CONFIDENTIALITY
Sessions are confidential to protect your rights to privacy. Telehealth services are performed through a HIPAA Compliant System.  It is your responsibility to find a space where you feel information cannot be overheard or misinterpreted by others. Please tell me if this is not possible and I can tailor the conversation accordingly.

Breaking privacy can occur if I have concern or evidence of; you being a risk of harm to yourself (mental or physical), you being a risk of harm to others (mental or physical), or someone is a risk of harm to you (mental or physical).  This includes if you disclose any of the above-mentioned risks.

PARENTS & MINORS
It is important that patients seeking therapy feel a sense of safety and security in their session for it to be most effective. My policy with minors is to gain a sense of trust with the patient as well as their parents. I will inform parents related to information they need to know (based on my discretion), related to their child. Anything that is considered a safety risk, the parents will be informed about immediately.  The patient will be able to choose how the disclosure occurs. The patient can choose if it is discussed all together, the patient sharing it alone where I am able to confirm what was shared, or myself sharing the information with the patient not present.

CONTACTING ME
Please be mindful that I am not immediately available by phone, text, or email. I have set aside time to respond to patients and typically try to respond within 24-48 hours. I will make every attempt to let you know if I have planned absences from the office and provide you with the necessary resources. I am NOT an emergency service so please utilize 911 for Emergency Services.

Thank you for taking the time to read through this and I hope it provided useful information to you. If there are any challenges in the therapeutic process, I hope that you will speak with me and give me the opportunity to respond to any concerns. I am happy to refer you to another therapist at any time and you are free to end therapy at any time.

Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.