HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

NOTICE OF PRIVACY PRACTICE AND INFORMED CONSENT

I am glad you have chosen me to assist you and would like to welcome you to my practice. The following notice is to  introduce you to your rights and responsibilities as a client in this practice and describes how medical information about you may be used or distributed and how you can access this information. I am required by law to maintain the privacy of your health information and to provide you with my legal duties and privacy practices with respect to your health information. If you have any questions about or would like more information about our privacy practices, please contact me at (469) 708-7650.

COUNSELING RELATIONSHIP

During the time we work together, we will meet weekly for approximately 50 minutes per session. Although sessions may be very intimate psychologically, we will have a professional relationship rather than a social one. Please do not ask to relate in any way other than the professional context of your counseling sessions. I do not accept friend or contact requests from current or former clients on any social networking sites. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy for both the counselor and the client. Because they can blur the boundaries of the professional relationship, they are not permitted. You will best be served if sessions concentrate exclusively on you. The counseling relationship is limited to the counseling sessions you arrange.

COUNSELOR QUALIFICATIONS

I have a Masters of Science in Counseling, with a specialty in play therapy, from the world’s top-ranked play therapy program, University of North Texas (UNT). I have worked with adults, teens, children and parents across several settings including university clinics, and hospital emergency departments and nonprofit agency settings.

I am a registered play therapist with years of experience in trauma and certified in Emotional Transformation Therapy™ (ETT™) which is a new form of therapy that rapidly alleviates emotional distress as well as physical pain. The term “transformation” refers to how quickly significant change typically occurs when ETT™ is used. It is a non-drug approach that can bypass the intellect and directly change human emotions.

EFFECTS OF COUNSELING

While benefits are expected from counseling, specific results are not guaranteed. At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discounting counseling. Counseling is a process of personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Some of these life changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together you and your counselor will work to achieve the best possible results for you.

CONFIDENTIALITY

Discussions between you and me, and even the fact that you are in counseling with me, are confidential. For this reason, if I see you in public, I will protect your confidentiality by greeting you only if you greet me first. With that said, all our communication will become part of the clinical record. Although I will keep our interactions strictly confidential and you are not required to waive your right to confidentiality at any time, limitations and exceptions do exist, including:

1) Authorization: You authorize a release of information with a signature.

2) Harm to Self/Others: I determine that you present a danger to yourself and/or others, including suicidal ideation, homicidal ideation, and threats to national security.

3) Abuse: You disclose to your counselor knowledge or founded suspicion of ongoing child or elder abuse

4) Court Order: I am ordered by a court to disclose information, including, but not limited to: testifying in a child custody or visitation case involving you, testifying in a lawsuit in which your mental health is an issue, or you have been charged with a crime, or you bring a negligence suit against Jenny Russell Counseling, PLLC. If records are requested or subpoenaed, this does not indicate an automatic release of records and I may choose to seek a court order quashing the subpoena or providing protection should disclosure be deemed not in the client’s best interest.

5) Professional Harm: You disclose sexual contact or other unethical professional conduct with another health professional in which you, or your child, had a therapeutic relationship.

6) Consultation: I may consult with another mental health professional about how to best serve you, in which case steps will be taken to protect your identity. 

7) Research and Training: Because I am in private practice, and may give professional presentations, I may discuss current clientele in the context of training and/or conference presentations. In this case, personal identifying information is protected.

8) Phone/Email/Texting: Modern means of communication including cell phone, email, and text messages have inherent limitations to privacy. I utilize a business cell phone. Your agreement below indicates you have been informed, understand, and accept the limitations should you elect to communicate with me through these mediums.

9) Public Remarks: Comments made about Jenny Russell Counseling, PLLC.’s services on public mediums (i.e. internet, Yelp, Facebook, newspapers, etc.) constitute an infringement upon your confidentiality. In the event you publicly remark about my services, you consent to allow me to use confidential information necessary to respond.

10) Other: I am otherwise required by law to disclose information.

 

In the event that I believe you are in danger, physically or emotionally, to yourself or another person, you specifically consent for me to warn the person in danger and to contact the following persons, in addition to medical and/or law enforcement personnel:

CLIENT RIGHTS

While some clients need only a few counseling sessions to achieve their goals, others may require months or even years of counseling; therefore, clinical need and treatment duration varies by client. As a client, you may end your and your counselor’s counseling relationship at any time though it is requested that you participate in a termination session. You also have the right to refuse or discuss modification of any of your counselor’s counseling techniques or suggestions that you believe might be harmful. Counseling services will be rendered in a professional manner consistent with the current ethical practices supported by the Texas State Boards of Examiners of Professional Counselors, HIPPA security and privacy rules and other state and federal laws. Other rights are as follows:

A. Right to Inspect and Obtain a Copy of Your Psychological Record: Professional records constitute an important part of the therapy process and help with the continuity of care over time. Records are kept of all of your and your counselor’s communications, including contact via phone and email, and are maintained in the form of paper files. Records are the property of Jenny Russell Counseling, PLLC and are stored in a locked filing cabinet behind a second locked door. Client records are disposed of seven years after the last point of contact. You have the right to inspect and receive a copy of your Clinical Record.

Additionally, should you or your legal representative direct or consent in writing for me to release your records, please be aware that a record preparation fee ($.50/page, minimum of $50.00) will be incurred and a “Release of Records” form must be signed. A copy of the record will be provided within 15 calendar days of the receipt of both. An overall counseling summary, in lieu of records, will be provided for upon request free of charge. In the case of shared custody of a minor, multiple individuals may have rights to the client’s record. If one guardian formally requests a copy of the records, additional copies may be provided to the other guardians who are actively participating in services.

B. Right to Request a Correction or Add an Addendum to Your Psychological Record: If you believe there is an inaccuracy in your clinical record, you may request a correction in writing. If the information is accurate, however, or it has been provided by a third party (e.g., previous therapist, primary care physician, etc.), it may remain unchanged, and the request denied. In this case, you will receive an explanation in writing, with a full description of the rationale. Additionally, you may request to place a copy of your written disagreement in your records. You also have the right to make an addition to your record, if you think that it is incomplete.

C. Right to an Accounting of Disclosures of Your Psychological Information to Third Parties: You have the right to know if, when, and to whom your psychological information has been disclosed.

D. Right to Request Restrictions: You have the right to request restrictions on certain uses or disclosures of your psychological information, beyond what the law requires. These requests must be in writing, and most likely will be honored, although in some cases they may be denied. We do not use or release your protected health information for marketing purposes or any other purpose aside from treatment, payment, and other exceptions specified in this notice.

E. Right to Request Confidential Communications: You have the right to request that your counselor communicate with you about your treatment in a certain manner, or at a certain location. For example, you may prefer to be contacted at work, instead of home, or on a cellular phone, to schedule or cancel an appointment. Or, you may wish to receive mail at a Post Office box, or at some other address. We prefer you submit such requests in writing and be specific with respect to how/when/where to contact you.

F. Right to a Copy of This Notice Upon Request: You have the right to request and obtain a copy of this Notice of Privacy Practices.

G. Right to Withdraw Permission to Disclose Health Information: You have the right to withdraw permission you have given us to use or disclose health information that identifies you, unless we have already taken action based on your permission and/or the limits to confidentiality previously noted. In order to take effect, your request to withdraw permission must be submitted to our office in writing.

H. Right to File a Complaint. If at any time for any reason you are dissatisfied with your counselor’s services, please let your counselor know so that existing issues can be worked through. If your concerns persist, you have the right to file a complaint if you believe your privacy rights have been violated. Complaints must be filed in writing, and may be addressed directly to your therapist, the Texas State Board of Examiners of Licensed Professional Counselors, or to the U.S. Department of Health and Human Services. If you have any questions or concerns about this notice or your health information privacy, please do not hesitate to address them during session or contact our office by telephone.

I. Right to be Notified in There is a Breach of Your Unsecured Protected Health Information (PHI): You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) our risk assessment fails to determine that there is a low probability that your PHI has been compromised.

CLINIC PROCEDURES

A. I operate under limited hours that often do not include weekends, overnights, or federal and/or state holidays. Counseling sessions are limited to prearranged times. As such, I do not provide 24-hour crisis counseling services as all services are provided by appointment only. Should you experience an emergency necessitating immediate mental health attention, call 9-1-1 or Crisis Line (866-260-8000) or go to the nearest hospital emergency room for assistance.

B. If a divorce or a separation of parents has occurred, a current copy of the relevant court documents is required to begin services. If joint custody exists, the parent not bringing the child will also be invited to participate in the counseling process. Either way, the counselor will reach out and connect with both parents, unless otherwise indicated by the courts. In any custodial arrangement, both parents have the right to contact the therapist and inquire about their child’s treatment progress, unless otherwise indicated by the courts.

C. The benefits you receive from counseling depends upon consistent attendance. Therefore, if you are absent three sessions in a row, your name will automatically be placed at the end of the practice waiting list.

D. Should you need to contact me between sessions, you may email at jenny@counselingnest.com or leave a voicemail (469)708-7650.

I reserve the right to postpone and/or terminate counseling with you in any of the following circumstances: (1) if you come to session under the influence of drugs/alcohol, (2) if you do not comply with the medication recommendations of your psychiatrist or physician, (3) if your counselor believes that you are not benefiting from counseling, and/or (4) if your account is delinquent.

FEES

In return for a fee, I agree to provide counseling services for you, your child, and/or your family. The fee for each session will be due prior to the commencement of each session. The rate for all subsequent therapy services such as: attending parent/teacher conferences, ARD meetings, classroom observations, interactions with insurance providers, phone calls over 10 minutes, etc. will be billed the same fee in 15-minute increments. You will be billed according to the standard mileage rate for any service that requires travel. All returned checks will incur a $30.00 return-check fee. Payment for services is due no later than 48 hours after a therapy session. If payment is not received, the next therapy session will be canceled until your balance is paid in full. If there are two or more instances of non-payment, payment will thereafter be required in advance. Fees are additionally charged for cancellations with less than 24 hours-notice and for court appearances; see below for more information.

Fee Structure for Jenny Russell Counseling, PLLC:

Therapy/Counseling:

$175 per session

Court Ordered Therapy or Court Related Therapy/Counseling*

$225 per session

Court Appearance/Deposition**

$250 per hour

 

*Individual (adult or child), Couple, or Family counseling that is either ordered by a court, as a result of an agreed court order, mediated settlement agreement, or Rule 11 agreement, or is in regard to, or related to a divorce, post-divorce court case or legal matter. Will also apply if referred by a Parenting Facilitator, Parenting Coordinator or Collaborative Professional. If you are attending therapy but do not meet the above guidelines, but have therapy treatment goals that are related to divorce, modification, blended family, children in the middle, child not executing the parenting plan schedule or other high conflict themes, you will still be billed at the higher session rate. Please talk with your counselor with questions or concerns regarding your treatment goals.

**Court/Deposition fees incurred include time for travel, preparation, and actual appearance time, billed at the stated hourly rate, with a 4-hour minimum charge. Payment is due and non-refundable 72 business hours in advance. Any additional time spent on the day of the court/deposition appearance will be billed within 24 hours and is expected to be paid in full within 48 hours of the bill being sent. Out-of-pocket expenses associated with travel shall also be billed to you with the same expectations of payment.

You agree that you are responsible for any legal fees that I incur as related to your case or treatment.

I reserve the right to suspend services if there is an unpaid balance in your account.

I operate as an out-of-network service provider and can provide you with all necessary paperwork needed for you to file for reimbursement with your insurance carrier. Most insurance companies will pay a percentage of each session after you meet your deductible; however, you will need to check with your insurance provider as specific coverage is contingent upon the individual plan you carry. Clients may also use their FLEX/HSA spending accounts to pay for services. Ultimately, it is your responsibility to inquire if your insurance policy will cover your counseling services. Furthermore, by committing to services you give Jennifer “Jenny” Rette Russell, LPC, RPT the right to seek the services of a bill-collecting agency in efforts to collect fees that remain unpaid to their practice for services rendered and/or for cancelled or missed appointments.

Should you elect to independently file an insurance claim in attempts to seek reimbursement, submitting such claims serves as authorization for our practice to release any information including the diagnosis and the records of any treatment or examination rendered to you or to your child during the period of such care to third party payers and/or other health practitioners.

OUTSIDE SESSION COMMUNICATION

Hours within the practice are based on scheduled appointments, and thus, vary at times. If you wish to reach me between sessions, you may leave messages at (469)708-7650. If you are in a life-threatening emergency, please call 911 or Crisis Line (866-260-8000). I am not able to provide emergency services; if you or I believe you need a greater level of care than can provided, I will arrange referrals to a mental health professional who is better able to meet your needs.

Cancellation
Our in-person contact will be limited to counseling sessions you arranged in advance. In the event that you are unable to keep an appointment, please notify either me at least 24 hours in advance. If no notification or less than 2-hour notification is made, a regular session fee will be billed to you. If less than 24 hour notice is provided a $50 charge will be assessed. Likewise, if you intend to discontinue counseling, please inform me immediately so that I may offer your time to another client.

Email/Text Communication
Please be aware that email is not a confidential means of communication, as all email communication is accessible by operators and mediators of the communication providers (Microsoft Outlook, G-mail, Yahoo…etc.). Should you elect to communicate with me via email, take note that I cannot guarantee complete confidentiality within this medium. Please do not send emails or text messages related to your or your child’s therapy sessions, as electronic communications are not completely secure and confidential. If you choose to email or text information regarding your therapy, your counselor will not confirm receipt and discussions regarding your concerns and/or needs will be postponed until your next scheduled session. Any electronic transmissions of information by you are considered part of the clinical record and retained in your file. Any emails or text messages received from you will become part of your therapy record.

How Quickly You Can Expect a Reply
While I try to check voicemail and email regularly, you have no way of knowing if I am unavailable due to illness, vacation, or other reasons, or if there are problems with the network itself. Additionally, there are several days of the week I work off-site. This means that your message may not be received immediately. Please take note that on days I am not away due to illness or vacation it may take up to 3 days to return your contact; if I am away due to illness or vacation it may take longer as I do not check email/voicemail when I am away from the office.

COURT APPEARANCES

Should you or your attorney subpoena me as a factual case witness or in court-related proceedings, you agree to pay $250.00 for every hour of your counselor’s time involved, including case preparation, phone calls with attorneys, travel and witness time. You further agree to pay a retainer fee of $1,000.00 at the time a subpoena is served, which will be applied toward these charges. A bill will be rendered to you for immediate payment when a subpoena is issued. Please let me know before establishing a counseling relationship if you are attending counseling for court or court-related purposes/motives.

 **Court/Deposition fees incurred include time for travel, preparation, and actual appearance time, billed at the stated hourly rate, with a 4-hour minimum charge. Payment is due and non-refundable 48 business hours in advance. Any additional time spent on the day of the court/deposition appearance will be billed within 24 hours and is expected to be paid in full within 48 hours of the bill being sent.  Out of-pocket expenses associated with travel shall also be billed to you with the same expectations of payment.

You are responsible for any legal fees that I incur as related to your case or treatment.

I reserve the right to suspend services if there is an unpaid balance in your account.

REFERRALS

Should you and/or your counselor believe that a referral is needed, your counselor will provide some alternatives, including programs and/or people who may be available to assist you. You will be responsible for contacting and evaluating those referrals and/or alternatives.

CHANGES TO THIS NOTICE

I reserve the right to modify privacy practices and terms at any time, as permitted by applicable law effective for all mental health information, including mental health information created and/or received before the changes. Before changes this notice will be updated and posted in the waiting room of the facility. In the meantime, please do not hesitate to raise any questions or concerns you might have about your confidentiality.

CONSENT FOR TREATMENT:

By signing this form, you are indicating that you have read and understood the contents of this document, and that any questions you had about this document were answered to your satisfaction. You also attest that you were furnished a copy of this document, acknowledge your commitment to comply with all terms and requirements. You confirm that you issue consent for Jennifer “Jenny” Rette Russell, LPC, RPT to work with you, your child, and/or your family and acknowledge understanding and agree to the fee schedule. You understand this consent can be revoked at any time through written request. Unless otherwise indicated, it will remain in effect until you revoke authorization in writing. My signature further indicates the following:

• I understand that there can be risks and benefits associated with therapy. I also understand that no promises have been made to me as to the results of treatment.
• I understand that I may leave therapy at any time and agree to discuss the termination of therapy with the counselor in person.
• I agree to pay the appropriate session fee at each counseling session.
• MINORS: In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardian of the child and that I have the legal right to authorize psychiatric/psychological services for the child under the terms of this agreement. As such, my consent is given for Jennifer “Jenny” Russell, LPC, RPT to treat the minor indicated below.    

It is no secret that there is a pandemic and important to understand that all of our activities, now, should take into account the risks and benefits entailed. In-person counseling has advantages over distance counseling done by telephone or by face-time platforms, but in-person counseling also entails risks that are avoidable. By agreeing to work in-person you also agree that you understand the risks and accept those risks. The COVID-19 virus often comes with no symptoms at all, but it can also be a very serious illness that may require medical treatment and in some cases, hospitalization. People may have the illness and not know they have it, but still transmit the illness to others – who may suffer a more serious episode of the illness.

Our office will exercise care by implementing the following steps:

1. We will attempt to schedule appointments ways that will minimize your contact with others. When you come to our office please maintain six feet of space between yourself and others in the waiting room, hallway and individual offices.

2. Between appointments, we will do our best to disinfect the office. No effort to disinfect an office space can be perfect. You can be safer and make others safer by not touching anything in the office that you do not need to touch.

3. If you, or if anyone in your family has any symptoms of the virus, you should notify us immediately, and you should cancel appointments, and not come to the office. There is a list of the symptoms offered by the CDC which is attached. If you do have symptoms we can continue to provide virtual services for adults and possibly children if therapeutically appropriate.

By coming to our office, you agree, you understand, and you accept the risks entailed. You agree to cooperate with our efforts to protect you, to protect others, and to protect ourselves and our staff, by following safe practices including the steps listed above. You have had an opportunity to ask any questions and your questions have been answered.