Practice policies.
RISK OF SOCIAL OVERLAP
Because Park Circle Counseling is a practice designed to align lived or similar experiences between client and therapist, this heightens the risk of social overlap with your therapist. Please make efforts to enjoy your social life and allow your therapist to do the same, even if these efforts cause encounters between you.
APPOINTMENTS AND CANCELLATIONS
When our office schedules your appointment, we are reserving a dedicated time slot. Our policy is that if you must reschedule your appointment that you must provide us with at least 48 hours notice. If you or your clinician are unable to reschedule within the same Mon-Sun week, you will be charged a late cancellation fee (typically the full cost of the session). Please understand that exceptions to this policy are unfair to clinicians and other clients.
If you miss 2 consecutive appointments or have excessive cancellations within 24 hours, any further scheduled or recurring appointments may be automatically cancelled.
TELEPHONE ACCESSIBILITY
If your provider uses text message communication, please limit texts to between 8:00 am and 9:00 pm. Messages outside this timeframe are subject to dismissal from the practice. You may use portal messaging 24 hours a day, but understand that your provider may not be able to answer or may delay answering. You may be billed for this time, and your insurance company may not cover telephone-based services. The practice cannot ensure the confidentiality of any form of communication through electronic media, including text messages.
Your clinician is not able to manage therapeutic needs outside of session. If an emergency situation arises, please call 911 or go to any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, clinicians do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). Adding clients as friends or contacts on these sites can compromise your confidentiality and your respective privacy. It also blurs the boundaries of your therapeutic relationship.
REPRESENTATION
Park Circle Counseling dedicates time to therapeutically representing some patients regarding gender affirmation, and thus cannot plan to provide representation in other legal proceedings in the interest of protecting that time. This includes family reunification and custodial arrangements, divorce mediation, court appearances, employer attestations, and emotional support animal provisions. Please understand that to achieve these goals, you will be given sufficient referrals to capable providers. Your therapeutic records are always available to you as per HIPAA and other regulatory policies.
TERMINATION
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. Providers may terminate treatment if deemed appropriate for your care or their safety. If therapy is terminated for any reason or you request another therapist, your provider or their representative will provide you with a list of qualified psychotherapists. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for one month (unless other arrangements have been made in advance), for legal and ethical reasons we may consider the professional relationship discontinued.
CREDIT CARD POLICY
All clients are asked to supply a credit card to keep on file.
You may choose to utilize insurance, PayPal, Venmo, CashApp, or credit card to pay balance at the time of each service, with the understanding that each payment method has limitations in HIPAA compliance. A credit card kept on file is a failsafe for payment issues and fees. This information is not retained in email, text, or paper storage. Credit card fees are included per transaction.
USING INSURANCE TO COVER FEES
You agree to furnish the practice with a copy of current health insurance card(s) if you are using insurance to cover your session costs. You also agree to provide an explanation of benefits and/or claim form(s) from your insurance company if requested. There is an inherent release of medical information and risk to confidentiality in transmitting session information to insurance companies, although every effort is made to mitigate risk.
Deductibles and co-payments/co-insurance are due at the time of service. You are responsible for any balances created by denial of claims to insurance and will be automatically billed for these. Any overpayment on your account will be paid to the appropriate party (i.e., insurance company, you). In the event the practice does not receive reimbursement within 45 days, we will contact your insurance company regarding the claim; you will be notified if we do not receive a response.
In the event you are unable to pay your responsibility in full, contact the office to discuss financial arrangements.
You may opt to use payment methods that are not considered HIPAA compliant. Our practice makes every effort to update and inform patients of payment methods as they become or cease to be HIPAA compliant, but the nature of financial transactions is not fully covered by HIPAA and financial transaction companies change frequently. You agree not to hold Park Circle Counseling accountable for the changes made by these companies.
Informed consent.
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. 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. Your provider cannot promise that your behavior or circumstance will change. They can promise to support you and do their very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
The session content and all relevant materials to the client’s treatment will be held confidential.
Limitations of such client-held privilege of confidentiality exist and are itemized below:
If a client indicates an intention to complete suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client indicates intention to cause 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 a minor (under 18 years old).
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.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I might acknowledge you with a wave or smile, but no further. 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, 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.
If you are using insurance to pay for your sessions, your provider may be required to assign a diagnosis and create a treatment and discharge plan.
Some concerns or diagnoses, substance use, and specific needs are best met by additional or other providers. Your provider may refer you to a higher level of care or may refer you to a provider who specializes in your areas of concern. This is part of your provider’s ethical obligation to provide the best possible care.
Some periodic assessments may be conducted to help your provider best serve you.
Your provider’s ability to speak on your behalf to outside parties such as employers is addressed on a case-by-case basis.
Records for minors 15 and under are legally accessible by legal guardians. Your provider has a responsibility to manage this sensitively and inquisitively.
Clients 16 years and older who have a legal guardian or third party as their financial guarantor should understand that charges, EOBs, and session dates/times/lengths will necessarily be disclosed to these parties.
You agree not to misrepresent symptoms or conditions in an effort to benefit yourself or someone else, or to discredit your provider.
The No Surprises Act of 2021 means that you have the right to be informed of treatment costs. Please discuss if you do not already understand your financial obligation prior to your first appointment.
Good Faith Estimate as of July 2024:
Services at Park Circle Counseling with a fully licensed clinician are as follows:
30 minute session - $105 (only scheduled by provider when appropriate)
40-45 minute session - $130 (only scheduled by provider when appropriate)
53-60 minute session - $155
Diagnostic Assessment - $180
Follow-up communication between sessions - $50/hour
Record review and letter composition - $100
Family diagnostic discussion - $130Provisionally licensed therapists - $110 for 50 minutes
Services with therapist interns are $30-$60 for 50 minutes
Your treatment plan depends on your personal, financial, and emotional needs.
Your diagnosis is available in your client portal, and may be sent to you in fomal documentation at any time.Rates are subject to change with notice.
Insurance coverage depends on your plan. Please see your provider.All fees not paid within 72 hours will be automatically applied. No show fees are not able to be claimed to insurance and are the entire fee. If you are not able to reschedule your appointment in the same Mon-Sun week, please understand that a no show fee will be assessed. Unfortunately, it is not fair to clinicians or other clients to make exceptions to this policy.
telehealth consent.
CONSENT FOR TELEHEALTH CONSULTATION BY THE CLIENT:
I understand that my health care provider wishes me to engage in a telehealth consultation.
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.
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.
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.
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 SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:
Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Telehealth by SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
Telehealth by SimplePracticefacilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in Telehealth by SimplePractice – or that such information is current, accurate or up-to-date.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
I am responsible for saving and maintaining the telehealth link and understand that a new link may not be sent to me at every appointment.
Privacy policy.
EFFECTIVE DATE OF THIS NOTICE This notice went into effect on 07/22/2018. NOTICE OF PRIVACY PRACTICES - PARK CIRCLE COUNSELING
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Unless otherwise stated, “you” refers to the client, and “I” refers to the clinician.
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. 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 personal 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 and complete information 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:
Progress and Psychotherapy Notes. I do keep “progress notes” and “psychotherapy notes” as the terms are 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.Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
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:
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.
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.
For health oversight activities, including audits and investigations.
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.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
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.
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.
Disclosures to others. I may provide your PHI to anyone that you indicate via Release of Information 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.
South Carolina age of consent to treatment is 16 years old. At the time of a minor’s 16th birthday, they are able to revoke access to records by legal guardians, even if these guardians continue to be financially responsible for the minor’s care. All minors 16 and older must initiate and terminate care directly.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
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.
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.
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.
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.
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.
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.
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.