INFORMED CONSENT FOR COUNSELING
Safrianna DeGroat
Therapy@Safrianna.com
(762) 441-0444
Safrianna.com
122 E. Patrick Street, Suite 108
Frederick, MD 21702
GENERAL INFORMATION
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
INTRODUCTION TO YOUR THERAPIST
My name is Safrianna DeGroat, a Licensed Clinical Professional Counselor (LCPC LC10745) in the state of Maryland. I received my Masters in Counseling: Community Mental Health from McDaniel College, though my first career was as an educator! I use a variety of techniques typical to therapists with mental health training. However, I also offer Internal Family Systems, Mindfulness & Mindfulness-Based Cognitive Therapy, Sand Tray, EMDR, and Expressive Therapies. I believe in holistic treatment, so we will discuss things like sleep, food, exercise, mindfulness, and/or spirituality throughout our work together. My practice is currently an individual therapy practice owned and operated by myself under the LLC Luna Counseling & Creative Services.
THE THERAPEUTIC PROCESS
Our therapeutic relationship is a collaborative one where you can feel safe to face whatever it is you need to overcome. You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstances will change. I can promise to support you and do my very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself and your future.
Due to the varying nature and severity of problems and the individuality of each client, I cannot predict the length of your therapy or guarantee a specific outcome or result. However, this will be discussed at the beginning of your treatment and throughout to ensure you are experiencing a positive outcome.
Appointment “Slots”: Sessions are typically scheduled once per week at the same time and day. I like to have my clients in the same “slot” each week for consistency. I may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome.
FEES, INSURANCE, & BILLING
Fees: My out-of-pocket fee for a fifty-minute session is $250.
The intake (first session) is $265 as I go extensively over your paperwork and create an individualized treatment plan for you.
For Couples appointments, I charge $285. Sessions where I meet 1 on 1 with a member of the couple are at the individual rate of $250. The first time I meet with a member of a couple, I charge the intake fee of $265.
In the case that you want or need a 75-90 minute session to do an in-depth EMDR or Internal Family Systems process, sessions are $300.
Fee Changes: I reevaluate my fees at a minimum of once yearly. In the case that you will be impacted by a fee increase, you will be given a two-month notice prior to it taking effect.
If your financial circumstances change, please notify me immediately to discuss possible referrals.
Insurance: I only take CareFirst BlueCross BlueShield plans, though if you have a different PPO insurance plan, I can support you in submitting for reimbursement from your insurance company. Payment must still be provided upfront, however.
In the case that I drop my credentialing with CareFirst BCBS, I will give you a minimum of two months notice. At that time we will discuss other options for payment and whether a referral to another provider is needed. In the case that your insurance changes, please notify me immediately to develop a plan to transition to the cash rate for sessions.
Payment & Billing: I take payment via Simple Practice/Stripe, cash, and checks. If using insurance, you will be sent a bill via Simple Practice/Stripe. In some cases, I may use Square for billing. Please be aware of your own insurance policies, copays, and deductibles. You should also be sure your insurance covers telehealth if you plan to use it. You are responsible for understanding these policies and any money that is owed for service. You are responsible for all fees if your insurance declines. Please note, it can take insurance companies a while to process claims; thus, you must be aware in advance if they plan to cover appointment fees.
If you have a PPO plan, I can assist you in trying to get reimbursement by submitting Superbills to your insurance. This is done through Reimbursify, an online reimbursement platform. Reimbursement is not guaranteed.
Unpaid Balances: I may halt our sessions if you have unpaid balances. When a copay or private pay fee is due, I ask that you pay it prior to our next scheduled appointment. If balances remain unpaid, I reserve the right to cancel upcoming appointments. After two weeks of a session going unpaid, I will bill the card on file. Please consult with me if a financial concern arises. If you cannot pay a balance for two weeks without an alternative plan, I will remove you from my caseload and refer you to alternative providers. You are still responsible for the unpaid balances, and if payment is not rendered in a timely fashion, may be submitted to collections or legal action pursued.
CREDIT CARD AUTHORIZATION
Clients are required to have a credit card on file. This card can be used to opt into autopay for ongoing appointments. It will also automatically be charged if the client does not appropriately cancel their appointment and the appointment is missed. Failing to have a working card on file will mean the client’s appointment slot is released.
CONFIDENTIALITY
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Consultation: Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
Exchange of Information: From the start of treatment, I will ask before speaking with any other treatment providers in order to have open communication and provide excellent care. You are not obligated to provide this release, and this can be discussed with me at any time. You can also revoke any release of information at any time.
Couples/Family Treatment: If you participate in couples or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release. Also, I will not disclose information communicated privately to me by one family member to any other family member without written permission.
Parent/Minor Confidentiality: Communications between therapists and patients who are minors (under the age of 16) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Therefore, I, exercising professional judgment, may discuss the treatment progress of a minor patient with the parent or caretaker. Minor patients and their parents are urged to discuss any questions or concerns on this topic with me.
Public Encounters: If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
RECORD KEEPING
Your records are maintained in a web-based system called Simple Practice. This means your records are stored online in a secure, encrypted, HIPAA compliant system, backed up to ensure records are not lost due to technical problems. This system benefits the client by including online payment, online scheduling, and secure messaging to your therapist. Please do ask any questions or report any concerns about online record keeping. As with any method of record-keeping, every foreseeable precaution has been taken to protect privacy, but there are no guarantees. You can learn more about the specific safety precautions in place here: https://www.simplepractice.com/security/
If you (or someone else) would like a copy of your records, please make this request to me directly. I may choose to provide a treatment summary if that is most appropriate in the situation. If you are to have your records copied, the fee is $4 plus 10 cents per page.
CANCELLATIONS & SICK POLICY
Cancellations: To cancel or reschedule an appointment, you are expected to notify me by phone or email at least 24 hrs. before your appointment. If you do not provide me with at least 24 hours notice in advance, you are responsible for a no show fee of $100.
If you cancel an appointment with less than 24 hr notice or no-call-no-show, you will be charged your appointment fee as I will be unable to schedule another client on such short notice. This includes your first appointment. This hour is reserved for you. I understand that all of us get sick, or that emergencies may arise. In the case that you are ill, but would still like to have an appointment during your reserved appointment time we can meet using the authorized online platform, Simple Practice. This will not incur a late cancelation fee.
Sick Policy: Therapy works best when it is regularly scheduled and attended. However, it is also important that you and I remain healthy. If you have a fever, body aches, or chills in the last 24 hours, we can cancel, reschedule, or move to a virtual session. Do not come into the office or waiting room. This policy is to keep you, your community, and your therapist healthy.
If I am ill, but otherwise able to meet, I will offer you your appointment online as well. If I have an emergency and must cancel last minute, I will do my best to give 24 hrs notice as well. You will not be charged for an appointment I must miss, and will be offered the opportunity to reschedule as soon as possible in the case that I am able to do so.
Weather Policy: The same policy is in effect for inclement weather. If you are concerned about driving for an in-person session, we can meet via Simple Practice teletherapy. In the case that you have no internet due to the weather, please notify me immediately and let me know if you are unable to meet via data. In some cases, I may offer your appointment via telephone call instead if you do not have a data package or usable internet at the time of our session.
VACATIONS & THERAPIST TIME OFF
I believe self-care is of the utmost importance. I try to take off a few weeks in the Summer and Winter, with a few days off here and there for mini-vacations. In the case that I will be taking any time off or must miss our appointment, I will do my best to give a minimum of 2 weeks’ notice. Typically, I know farther in advance if I am planning for any significant amount of time off.
I also continually pursue higher education and training to better my services to clients. For the same reason, if I am going to be off for training, I will do my best to notify you at least two weeks in advance. Alternative appointment times may be granted in such cases.
In the case that I am going on vacation for a period of more than one week, I will provide you with other resources upon request should you need to talk with someone.
EMAIL & TEXT
Email: I will respond to emails for scheduling purposes, words of inspiration, or resources only. Email is not to be used for emergencies. Email is not always guaranteed to be a secure or confidential means of communication. I do not check my email outside of my working hours, nor do I take phone calls during those times. This is to maintain professional boundaries, maintain my own self-care, and to help us establish other support networks. I am not an emergency care provider.
Text: Text messages are for rescheduling appointments, to notify me if you’re running late, or if you’re having a technology issue while trying to access an online appointment. Text messages are not always monitored, and should not be used for emergency purposes.
Social Media: Please see my Social Media & Communication Policies for additional information.
TELEHEALTH
Telehealth is offered via Simple Practice / Telehealth, a HIPAA compliant video platform. You will be provided a link and password to the email of your choice when you sign up via the Portal. In order to maintain confidentiality, you should not be in a room with another person and should wear headphones if possible.
As part of my private practice, I conduct virtual therapy sessions through an internet connection or via telephone, when appropriate. Tele-mental health is communicating directly with each other where we can see and/or hear one another but is not an in-person face to face session. Tele-mental health is not reimbursed by most third-party payors. Check with your insurance in advance if you plan to pursue reimbursement. As you will not be present in my office during your session, please be aware of your own confidential space where you chose to connect with me. I use industry best practices and third-party services that align with HIPAA standards for telehealth to ensure both confidential client interaction and the security of the communication medium. I cannot control the quality of the connection. It may be choppy or delayed, in which case, we can discuss whether to continue the session by phone. A hard-wired Internet connection will provide the best picture and voice quality. If you are using a hotspot instead of WIFI to connect to the session, please be aware of increased data usage. In such cases, we can discuss whether to conduct the session by phone. As I will be working with you remotely and won't be able to provide services to you in an emergency, I encourage you to note the contact information of helpful resources and emergency services provided in this informed consent.
Address at Time of Appointment: Please notify me of the address of your present location if different from that on your intake at the time of our session. I will continue to assess and check in with you on the appropriateness of this mode of therapy for you at this time and discuss alternative referrals if necessary.
SESSION POLICIES
Late Arrivals to Appointments: If you will be more than 10 minutes late to your appointment, please contact me. If you do not contact me and have not shown up 15 minutes after the start time of your session, I will close out the room if it is for teletherapy. If you arrive late, you do not gain back more time. Your 50 minute session begins at either :00 or :30 and ends at either :50 or :20, accordingly, regardless of time you arrive.
Use of Cellphone: Please refrain from using cell phones during your session time (unless you are using your phone to call into your appointment). Please put your cellphone on silent. If you have concerns about this policy, please discuss with me in session.
Drug & Alcohol Use: Please refrain from the use of drugs or alcohol at least six hours prior to the session. This includes marijuana. While I am a marijuana supportive counselor, marijuana can impact session outcomes and halt treatment progress when used too close to therapeutic work. It is advised to refrain from using marijuana for at least five hours after a session where possible, especially if you have engaged in EDMR.
Inviting an Additional Party to Session: If you would like to have a family member or other person join your session, please discuss with me prior to the session to make arrangements.
RISKS & BENEFITS OF THERAPY
Therapy is intended to help you develop better coping, and increase satisfaction with your life and relationships. You will discuss your expectations for therapy at the first session. Psychotherapy is known to improve moods, relationships, and other areas of wellness.
During the course of therapy, some of your assumptions, perceptions, or behaviors may be challenged, which can cause you to feel very upset, angry, depressed, or disappointed. You may experience some unwanted or surprising feelings that can arise through therapy. You are encouraged to explore those feelings during sessions, as it is part of the therapeutic process. In attempting to resolve issues that originally brought you to therapy, other unintended changes in you and your interpersonal relationships may result.
There are other treatment options you can discuss with me as you assess your own personal risks and benefits of psychotherapy.
I will monitor outcomes in session, tracking to ensure the therapeutic process benefits you and has a positive impact. These assessments may be from a brief form you complete or from a direct conversation with me.
COMPLAINTS
If at any time you are not satisfied with your treatment, please discuss this with me in session. If you have a complaint you would like to report, I am licensed under Maryland’s Board of Professional Counselors and complaints may be filed following the process found at https://health.maryland.gov/bopc/Pages/complaintold.aspx.
TERMINATION
The length of your treatment and the timing of the end of your treatment depends on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for its end, in collaboration with your therapist, who will discuss a plan with you for termination as you near 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.
It is my goal to only ever ethically terminate clients. I will terminate if 1) the client determines they would like to terminate, 2) I feel I do not have the expertise necessary to best handle your case and will make a minimum of two referrals to other providers or treatment centers, or 3) I plan to move out of state or retire, giving a minimum of 3 months notice.
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. Clients who routinely reschedule may lose their spot as appointment times are held per individual client.
IN CASE OF EMERGENCY
I do not monitor my phone and email at all times. While I do check my phone and email during business hours, I may be with a client at any time during those hours. Should you find yourself in an emergency, please contact 911 if you are in danger, contact 211 for mental health crisis services, or contact a crisis hotline such as:
National Suicide Prevention Lifeline 800-273-8255
Text HOME to 741741 for a Crisis helpline.
Maryland’s Crisis Hotline is available 24 hours/7 days a week to provide support, guidance and assistance. Call 211, press 1.
I am happy to support you in getting access to a higher level of care in the case that you need additional or emergency services. Please note that I do not monitor my email or phone outside of my typical business hours (As of 10/4/2020, 9 AM-7 PM, Sunday, Monday, and Thursday). If you are in immediate danger, please contact one of the above numbers.
PERMISSION FOR TREATMENT
I consent to receive mental health counseling from Safrianna DeGroat. These services may include individual counseling or couple’s counseling. BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.