Please read carefully the information provided below as it pertains to the overall psychological treatment and/or mental health support you will be receiving. Before you begin therapy, it is important that you fully understand your rights and responsibilities as a client of Ease Mind Body Spirit LLC.

Financial Understanding
I understand that regularly priced scheduling rates are:

$100 for a 60-minute session (individuals)
$120 for 60-minute sessions (couples)
$140 for the initial intake 90-minute session
$140 for any extended sessions (90-minutes)

I understand that any other rates such as sliding scale and/or special introductory discounted rates may be subject to change after an agreed upon time period or limited time offer reaches fulfillment. And, I understand this change will mean that regularly priced scheduling will apply moving forward unless a new sliding scale and/or special discounted rate is discussed and agreed upon in writing.

Hours of Operation
Your counselor is not available after specified business hours and do not answer phones when in session. At these times, you may leave a message on their confidential voicemail and your call will be returned within one business day with the exception of holidays and weekends. In emergency situations, please contact your family doctor, go to your nearest emergency room, or dial 911.

Cancellation and Rescheduling Policy
In order to allow for proper scheduling and fair treatment to all clientele, please give the office a 24-hour notice of cancellations or rescheduling needs. If a 24-hour notice is not given in the case of a missed or late appointment, a fee of $50 will be incurred and implemented. In the case of unforeseeable emergencies, clients may contact the office and the fee may be waived at our discretion. If cancellations and rescheduling of session become habitual, client will be terminated and referred to another mental health professional. This policy is further detailed in our cancellation policy form.

Limits of Confidentiality
I understand that although the Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protections and patient rights about the use and disclosure of my Protected Health Information (PHI), federal and state laws also require abuse, neglect, domestic violence, and threats to be reported to social services or other protective agencies by my therapist. If such reports are made, they will be disclosed to me or my legal representative unless disclosure increases risk of further harm or injury.

Terminating Therapy
I understand termination of therapy is best discussed with my therapist at least one session before termination to allow for proper scheduling and documentation.

Client Rights
 - You have the right to ask questions about the therapeutic procedures or methods used during therapy at any time.
 - You have the right to participate in the ongoing creation and/or revision of counseling or treatment plans.
 - You have the right to refuse to discontinue any services or modality changes and to be advised of the consequences of such refusal.
 - You have the right to obtain clear information about your records.
 - You have the right to the maintenance of confidentiality. All therapeutic communications, records, and contacts will be held in strict confidence and only be related to applicable professionals, supervisors, and/or internal agency support actively involved in the client's overall treatment. However, there are limits to confidentiality. Information can and will be released in accordance with the state law if/when any of the following occur: risk of self-harm or harm to others.

NOTICE OF PRIVACY PRACTICE PATIENT ACKNOWLEDGEMENT
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI). Your mental health provider may use or disclose your PHI for treatment and health care operations purposes only with your written authorization. You may revoke all such authorizations at any time, provided each revocation is in writing.

RECORD KEEPING
Your mental health provider is required to keep appropriate records of the psychological services that are provided. These records are kept in a timely manner intended to facilitate the delivery and continuity of services. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. You have the right to request that a copy of your file be made available to any other health care provider at your written request. Additionally, you have the right to request a copy of your file for personal use (in unusual circumstances that involve danger to yourself this request will have to be further assessed). Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically with limited access by other users or in a paper file and stored in a locked cabinet in a confidential area.

SERVICES FOR CHILDREN/MINORS
If a client is under the age of 18 and not legally emancipated, they should be aware that the law allows parents to examine their child's treatment records, unless the counselor believes that such a review would be harmful to the client and to his/ her treatment. Before providing any information to the parents/guardians, counselors will discuss the need to do so with the patient and if possible, respond to any objections raised by parents.

For parents that are divorced or do not live together with child, the office reserves the right to review legal paperwork showing that they have the right to access medical records and/or counseling (psychological services) for child. We cannot release records to anyone unless they can show proof of having the right to access that information.

I verify that I am the legal guardian or parent, managing conservator, or person designated by the court to have the authority to consent to provide psychological services for child listed below. I attest that I am authorized to grant this consent for professional services and request that therapeutic services be provided for my child,

INFORMED CONSENT
This document serves as your informed consent. Your signature below indicates that you have read this agreement, agree to its terms, and consent to engage in therapy/counseling.

No-Show and Late Cancellation Policy

1. I understand that I will be charged a late cancellation or no-show fee of $50 if I fail to give at least 24 hour notice prior to canceling my appointment.

2. I understand that payment is due before additional appointments can be made.

3. I understand that these charges are an out of pocket expense and that my insurance carrier will not cover these charges.

4. I understand that the therapy session will last 60 minutes. If I am late to the appointment, session will end at the allotted time.

5. I understand that if 2 or more no-shows occur, Ease Mind Body Spirit LLC has the right to terminate services at any time.

6. I understand that Ease Mind Body Spirit LLC may utilize my payment methods on file for any balances, including late cancellation and no-show fees, without additional authorization.

STATEMENT OF INFORMED CONSENT: My signature below indicates that I have read the information in this document and agree to abide by its terms during my professional relationship with Ease Mind Body Spirit LLC.

This document outlines my office policies related to the use of social media. Please read it to understand how I conduct myself on the internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us online.

If you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the internet changes, there may be times when I need to update this policy. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy.

Friending
I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, Google Plus). 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.

Following
I keep several online social media business pages and accounts (Facebook, Instagram, Linkedin, etc.) for Ease Mind Body Spirit LLC for my professional practice to allow people to share my posts and practice updates with other users. I have no expectation that you as a client will want to follow either of these pages. All my posts are open and these pages can be read without formally following either account. Please keep in mind that following either account and/or posting responses creates a likelihood of compromised client confidentiality.

My primary concern is your privacy. You are welcome to use your own discretion in choosing when and how to follow me, if you are interested in doing so.

Note that I will not follow you back. I only follow other mental health professionals (as well as my family and friends) and do not follow current or former clients on any social media site. My reasoning is that I believe casual viewing of my clients' online content outside of the therapy hour can create confusion in regard to whether it's being done as part of your treatment or to satisfy my personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationships. If there are online things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together, during the therapy hour.

Interacting/Messaging
Please do not use messaging on Social Networking sites such as Twitter, LinkedIn, or Facebook to contact me. These sites are not secure and I may not read these messages in a timely fashion (and often do not get notification at all from the site that they have been sent). Do not use wall postings, @replies, or other means of engaging with me in public online if we have already established a client/therapist relationship. Engaging with me in this way could compromise your confidentiality. 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.

Please do not use SMS (mobile text messaging) unless we have already determined the parameters of this, and you have signed a contact form acknowledging that texting is not HIPAA compliant. As a general rule, texting is only appropriate for confirming appointments, letting me know you are running late, etc., and not appropriate for lengthy conversations about your treatment needs.

If you need to contact me between sessions, the best way to do so is by phone. Direct email at marleen@easemindbodyspirit.com is second best for quick, administrative issues such as changing appointment times. See the email section for more information. Please remember that my phone is typically not answered after hours, unless we have agreed that I would do so. I am also not a crisis or emergency services provider, so please call 988 and or 911 if in crisis or go to your nearest emergency room in the event of an emergency.

Use of Search Engines
It is not a regular part of my practice to search for clients on Google, Facebook, or any other web search engine or social media site. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our 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 check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.

Business Review Sites
You may find my practice 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. Please be aware that I do not add myself to these sites, therefore this will be the case if you see me listed. Please also know that my listing is not a request for a testimonial, rating, or endorsement from you as my client. While I often am sent clients through referrals from other practitioners and current or former clients, I do not ever seek public testimonials in regards to my professional counseling/psychotherapy services. Again, this is to protect your privacy. Nor do I want you to feel pressured to recommend me in any regard for my professional services.

Of course you have the right to express yourself on any site you wish. But due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or
negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. Remember that even web content that is deleted is still archived for review and can be accessed by others. Including your friends, loved ones, and employers. You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, there is a good possibility that I may never see it. My hope is that you will feel comfortable enough with me to share any concerns you may have directly with me, so we can work to resolve them together, whenever possible.

Remember that confidentiality means I cannot tell people you are my client, without your informed consent. You are more than welcome to tell anyone that I am your therapist or how you feel about treatment I have provided to you, in any forum of your choosing. If you do choose to write something on a business review site, I hope you will keep in mind
that you may be sharing personally revealing information in a public forum that will be archived even if deleted. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection.

If you feel I have done something harmful or unethical and you do not feel comfortable discussing it with me, you can also communicate directly with my licensing agency at:

Texas State Board of Examiners of Professional Counselors
Complaints Management and Investigative Section
P.O. Box 141369
Austin, Texas 78714-1369
https://www.dshs.state.tx.us/counselor/lpc_complaint.shtm
or call 1-800-942-5540 to request the appropriate form or obtain more information.

Location-Based Services
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. I do not place my practice as a check in location on various sites such as Foursqare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your devise, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office. Please be aware of this risk if you are intentionally "checking in," from my office or if you have a passive LBS app enabled on your phone.

Email
I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers, and not all providers use encrypted servers. 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 emails I receive from you and any responses that I send to you become a part of your legal record.

Conclusion
Thank you for taking the time to review my social media policy. If you have any questions or concerns about any of these policies and procedures regarding our potential interactions on the internet, do bring them to my attention so we can discuss them. Please sign below to indicate that you have read and understand my social media policy. Any changes I make to this policy will be provided to you, with the opportunity to sign an updated agreement regarding those changes.