Forms and Polices
I am available by appointment only Monday, Wednesday, Thursday, and Friday evenings from 5pm-9pm and Saturday from 10am-3pm. Individual sessions are conducted for 45-60 minute sessions at the time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and “you alone.”
If you need to cancel or reschedule, please provide a 24 hour notice. If you miss a session without canceling, or cancel with less than 24 hour notice, you may be required to pay for the session (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies DO NOT provide reimbursement for cancelled sessions. If cancellation is a frequent concern (without an excuse more than 2 times) you may be charged a $50 cancellation fee.* The fee will be required before scheduling future appointments.
If you are more than 20 minutes late for your appointment and have not called to notify me, I may not be available to see you. In the event you arrive late and are able to be seen, your appointment will still end at the scheduled time (if other appointments are scheduled) and you will be billed for the entire session.
*Medicaid recipients are exception to this policy
In the event of inclement weather (snow, ice, etc.); please contact the office to confirm that the office is open. Office closings will be determined by 8am.
You can stop therapy at any time, with no obligation to me other than to pay for services rendered and to give adequate notice of decision to cancel as discussed above.
Initially, I will schedule appointments weekly, however depending on your needs and situation sessions may be infrequent (biweekly, monthly, as needed). I will leave it up to you to schedule appointments. I will place you in an inactive status after 3 months of no contact.
I have the right to terminate treatment in the event I am not able to provide therapy that fits your needs, if you are not benefiting from the therapeutic relationship, if you do not pay for services as agreed, if you become violent, abusive, or the therapeutic relationship is compromised due to unforeseen circumstances. If therapy is terminated I will provide an appropriate referral.
Cost of Services for Self-Pay Client(s)
You are responsible for paying at the time of your session unless prior arrangements have been made. Payment is accepted by Cash/Debit/Credit Card. To receive a sliding scale fee, you must present proof of income through recent pay stubs. Please review the fees here. Fees are subject to change at the discretion of the therapist.
Cost of Services for Insured Client(s)
Co-pays, when applicable, are due at the end of each session. You may be expected to pay for the full cost until your annual deductible is met. (Please review your policy prior to initial session).
Contact and Communications
I am often not immediately available by phone. I DO NOT answer my phone when I am with clients or otherwise unavailable (trainings, meetings, vacation, etc.). At these times, you may leave a message on my confidential voicemail and your call will be returned within 24 hours, with the exception of weekends, holidays or vacations. (SEE EMERGENCY POLICY) if you cannot wait for a return call.
24-hour Crisis Coverage for Behavioral Health Emergencies
My office phone, email, text messaging or other social media sites ARE NOT an emergency access point. Should you require immediate psychiatric attention or find yourself in crisis, please call 911.
Please be aware that if you require my personal attention call 704-780-6066 for the quickest response, however I may be in session. I will make every attempt to return calls/text identified as EMERGENCY within 2-4 hours.
If I will be out of the office for extended leave (trainings, vacation, or medical leave) I will communicate this information with you in advance if planned with guidelines on whom to contact in my absence. If unplanned I have a policy in place for communication (SEE Access to Records).
Electronic Communication Policy
Please utilize email to communicate regarding administrative reasons ONLY (arrange or modifying appointments, billing information, etc.) Please DO NOT email content related to your therapy sessions, unless otherwise discussed. Email communication IS NOT completely secure or confidential. Any emails received or responded to will become part of the service record.
Text messages are to be used on a limited basis to communicate cancellations or if you are running late for your session. Please DO NOT text or use other messaging on social media such as Twitter, Facebook or LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely manner.
Social Media Policy:
DO NOT use wall posts, @replies, or comments to engage with me online if we have an established therapeutic relationship. Engaging with me in this manner can compromise your confidentiality. See Social Media Policy
If you need to contact me between sessions, the best way is by phone at 704-780-6066 by leaving a message on the confidential voicemail or direct email at firstname.lastname@example.org
Information you share with me is protected by law and by my professional ethics. If you wish to have information released, you will be required to sign an Authorization to Disclose Health Information form. There are exceptions to this policy. By law, all suspected child abuse and/or neglect must be reported; if it is suspected that individuals are a danger to themselves or to others action must be taken to contact authorities and the intended victim/respondent of harm. Information may be disclosed for insurance and billing purposes/or ordered by a court. Additionally, I may consult with other professionals in order to give you the best service. In the event I seek consultation no identifying information would be released. See Limits of Confidentiality
Confidentiality and Group Therapy
The nature of group therapy makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be cautions that there is no guarantee that other group members will maintain your confidentiality. I will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. I have the right to remove any group member for violation of the confidentiality rule.
Confidentiality and Technology
Email and Text messages should NOT be used to communicate sensitive health information. Emails will become a part of your service record. Every effort will be taken to safeguard your information, however cannot be guaranteed that unauthorized access to electronic communication could not occur. At this time email and text messages are to be used for appointment cancellation and/or scheduling of appointments. In the future if online counseling is utilized A Moment For You, PLLC will ensure the technology is HIPPA compliant and the client/consumer is aware and trained to use appropriate technology.
Confidentiality Training for Staff
New hires and/or interns will be trained in Privacy Practices to include HIPAA, requirements for 3rd party billers, professional ethics and security to protect clients/consumers and A Moment For You PLLC. Training will be offered during the “new hire” process, yearly, and as needed based on performance. Each new hire/intern will sign a formal Confidentiality Agreement at the end of the training acknowledging completion and understanding.
The policy is in place to ensure safeguards against loss, tampering , use, or disclosure by unauthorized persons and shall ensure that service records are accessible to authorized users at all times.
Initial paperwork to include client information form, treatment consents, authorization to release information, HIPPA form, diagnostic assessment, service plan, service notes, and billing records, and any work shared and completed during therapy will become part of your client file. Records are kept to ensure goal compliance and continuity of care. The client file will not be shared except with respect to the limits of confidentiality discussed in the Confidentiality Section. If the client/consumer wishes to have their record released, they are required to sign an Authorization to Release/Disclose Health Information form which outlines specific information to be released and to whom.
Storage and Maintenance of Service Records
Records will be kept either electronically on a USB drive and/or in a paper file and stored in a locked cabinet/briefcase in my office. Records will further be backed up to an external hard drive after 3- months of inactivity. Records will be kept for a minimal of seven years.
Efforts shall be made to ensure that the record(s) are package safe and securely when providing services outside of the office (field-based therapy). When service record(s) are transported by motor vehicle, the service record(s) shall be secured in a locked compartment (ex. Locked trunk or locked briefcase).
Access to Records
In the event I am ever unable to continue providing therapy, either temporarily or permanently; I have requested for my colleague Nichole Gause, MSW LCSW and/ or Datavia Spears, BSW contact my client/consumers in order to offer continued services or a referral. The above listed colleagues will have access to my client’s names and contact numbers. This information will be reviewed and updated as needed at a minimal of bi-annual.
Interns and/or other business associates (employees, contractors, etc) may have access to your service records as well in order for them to do the job/tasks we ask them to do (appointment reminder system, scheduling, etc). When we do this we require that interns/business associates keep health information about you private. A Moment For You PLLC provides confidentiality training to new hires and interns during “new hire” process, yearly, and as needed based on performance.
Accessing and Disclosing Information from the Service Record
Individuals have a right to access the information in one’s own service record. Individuals will need to request in writing a copy of the service record and complete the Authorization to Release/Disclose Health Information form if requesting partial or full service record be released. A Moment For You, PLLC will have 72 Hours (3 business days) to provide the items requested. Designated personnel will prepare copies and provide based on the agreed delivery method (mail or office pick up).
Designated personnel will offer to review the service record with the client/consumer to provide explanation and guidance to assist the client/consumer in understanding documents and impact of information being requested.
Live Life for the moment because everything else is uncertain-Louise Tomlinson