Consent for Telehealth Consultation

CONSENT FOR TELEHEALTH CONSULTATION

I understand that I or 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 SIMPLE PRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. 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 SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates 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 the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

Notice of Privacy Practices

EFFECTIVE DATE OF THIS NOTICE: This notice was last reviewed on March 26, 2024

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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 I have about you. 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:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

For my use in treating you.
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.
For my use in defending myself in legal proceedings instituted by you.
For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
Required by law and the use or disclosure is limited to the requirements of such law.
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
Required by a coroner who is performing duties authorized by law.
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 family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate 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.

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. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

Credit Card Authorization Form

By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement. You have the right to request a paper copy of this document.

I authorize AtReef LLC to charge my credit card through Stripe. I also agree that my credit card can be charged for any session that is not canceled at least 24 hours prior to the scheduled session.

I understand that this credit card will also be used for all fees that have not been paid within 30 days. You will be provided a receipt for all payments upon request. You may revoke this agreement at any time by providing a request in writing.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify AtReef LLC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

Credit Card Authorization Form

I authorize AtReef LLC to charge my credit card through Stripe. I also agree that my credit card can be charged for any session that is not canceled at least 24 hours prior to the scheduled session.

Informed Consent for Psychotherapy

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.

The Therapeutic Process 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 repeating patterns, as well as to help you clarify what it is that you want for yourself.

LIMITS OF CONFIDENTIALITY

The following contains important information about limits of confidentiality and practice policies. Non-therapy services such as coaching and non-therapy intensives are not subject to limits of confidentiality and HIPAA requirements that are stated below. To best inform you, this document contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires your therapist to make available a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice is available for review upon request and explains HIPAA and its application to your personal health information in greater detail.

Limits of Confidentiality

Confidentiality is an ethical concept that prohibits a psychologist or counselor from releasing information about the client. Privileged communication is a legal term for a right that belongs to the client that restricts a psychotherapist from disclosing, in legal proceedings, information that was given with assumed confidentiality. Confidentiality and privileged communication remain the rights of all clients of psychotherapists according to state law. A therapist can only release information about a client’s treatment with a client’s signature on a written Authorization form that meets certain legal requirements imposed by HIPAA. Confidentiality and privileged communication are maintained within AtReef LLC as a practice. There are some situations where a therapist is legally obligated to take actions, which are believed to be necessary to attempt to protect others from harm, and the therapist may have to reveal some information about a client’s treatment.

The limits of confidentiality are as follows:

If there is clear and immediate probability of physical harm to the client, information may be disclosed to take protective action, including communicating the information to the police or seeking hospitalization of the client.
If there is knowledge or reason to suspect that a child under the age of 18 (or other depending on state law) is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires the therapist to file a report with the Texas Department of Family and Protective Services (The requirements may vary depending on other states). Once such a report is filed, the therapist may be required to provide additional information.
If there is knowledge or reasonable cause to suspect that a vulnerable adult has been or is being abused, neglected, or exploited, the law requires that the therapist file a report with the Texas Department of Family and Protective Services (The requirements may vary depending on other states). Once such a report is filed, the therapist may be required to provide additional information. The therapist will not, if at all possible, inform such parties without first sharing that intention with the client. Every effort will be made to resolve the issue before such a breach of confidentiality takes place. Please bear in mind that the therapist is not able to give legal advice. There are some situations where the therapist is permitted or required to disclose information without either your consent or Authorization.
If the client is involved in a court proceeding and a request is made for information concerning diagnosis and treatment, such information is protected by the psychologist/counselor-patient privilege law. The therapist cannot provide any information without the client (your legal representative’s) written authorization, or a court order. Clients may want to consult with their attorneys to determine whether a court would be likely to order the therapist to disclose information.
If the client discloses that a person from whom they previously sought counseling in the States and behaved toward them in a sexually inappropriate manner, that counselor/therapist must be reported. The client’s identity may remain anonymous at their request.
If a client files a worker’s compensation claim and AtReef LLC is providing necessary treatment related to that claim, AtReef LLC must, upon appropriate request, submit treatment reports to the appropriate parties, including the client’s employer, the insurance carrier or an authorized qualified rehabilitation.
If a government agency is requesting the information for health oversight activities or to prevent terrorism (Patriot Act), within its appropriate legal authority, the therapist may be required to provide it for them.
If a client files a complaint or lawsuit against AtReef LLC or the therapist, relevant information about the client may be disclosed in order for AtReef LLC to protect itself. If any of these situations arise, the AtReef LLC will make every effort to discuss with the client before taking action and would limit disclosure to what is necessary.

Professional Records

Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that AtReef LLC receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier.

Except in unusual circumstances that disclosure would physically endanger you and/or others or makes reference to another person (other than a health care provider) and AtReef LLC believes that access is reasonably likely to cause substantial harm to such other person, you may examine and/or receive a copy of your Clinical Record, if requested in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, AtReef LLC recommends that you initially review them in your therapist’s presence or have them forwarded to another mental health professional so you can discuss the contents. AtReef LLC may charge a copying fee of $2.00 per page. If AtReef LLC refuses your request for access to your Clinical Records, you have a right of review, which your therapist can discuss with you upon request.

Patient Rights

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. The Notice explains HIPAA and its application to your personal health information in detail and is available for your review.

Social Media

Clients are free to follow any AtReef LLC social media platforms which are made for the general public. Should a client choose to follow a social media platform, it is possible that they will be followed in return as social media is not entirely run by the therapist but by a third-party as well. Clients that follow AtReef LLC social media are asked to adjust their privacy settings to their desired specifications when they initiate this online connection. To preserve the therapeutic relationship, your confidentiality, and ethical conduct, your therapist will never personally follow you or accept friend requests on their private accounts or on behalf of the practice. If working within a coaching relationship, your coach may support you online as deemed appropriate.

Educational Video Content Disclosure:

I may occasionally share videos with you, primarily intended for informational and educational purposes. These videos are not a substitute for therapy, nor are they to be interpreted as therapeutic advice. If you have questions or concerns related to the content of these videos, please reach out for clarification.

The sharing of these videos does not obligate you in any manner. You are not required to join, subscribe, or take any specific action in relation to the content shared. Your choice to view or disregard these videos is entirely at your discretion.

Please note that as the provider, I am not responsible for any reactions or outcomes you may experience after viewing the videos. If the content is triggering, not helpful, or leads to unintended consequences, I cannot be held accountable. Always exercise your own judgment and seek professional guidance if needed.

Furthermore, you have the right to request that I refrain from sharing such videos with you. If you ever wish not to receive these educational videos, kindly inform me, and your preference will be respected.

Email and Text message

Upon becoming a client at AtReef LLC, we will contact you via email, call, and/or text for scheduling purposes, appointment reminders, and limited between session contact for best care. We may also include you on email newsletters to best keep you informed which you are welcome to opt-out of at any time. While emails are encrypted, we cannot guarantee full confidentiality when communicating electronically via email or text and thus advise you to limit sensitive communications to in-session and proceed with the understanding of confidentiality limitations when communicating electronically.

In-house Consultation

At AtReef LLC, confidentiality is upheld to the highest legal standards. As the sole therapist, Ehsan Adib Shabahang, LPC, maintains this principle throughout all interactions. In situations where multidisciplinary consultation might be beneficial for client care, it's important to note that no identifiable client information will be disclosed without proper authorization. These situations might include referring a client to additional healthcare providers, where consultation is considered a best practice under state therapy licensing guidelines.

Sessions Outside of the Office

Occasionally, it may be beneficial for treatment objectives to conduct a session outside of the conventional office setting. For instance, a client struggling with anxiety in crowded environments may find it advantageous to engage in exposure therapy at a bustling coffee shop under my guidance. Before proceeding with such out-of-office interventions, I, Ehsan Adib Shabahang, LPC, will thoroughly discuss the potential benefits and logistics with the client. Sessions outside the office will only take place with the client's explicit verbal agreement.

CONSENT FOR PSYCHOTHERAPY/COUNSELING, ASSESSMENT, AND/OR COACHING

Choosing to engage in psychotherapy is a meaningful decision, and I, Ehsan Adib Shabahang, LPC, am honored that you've chosen to pursue this journey with AtReef LLC. Your commitment to this process is crucial for a transformative therapeutic experience. I place a high value on crafting a safe and supportive therapeutic space, and will make every effort to earn your trust and maintain the integrity of our professional relationship. Your success in therapy is partially dependent on your desire for change and your openness and honesty during our sessions. Openness to experiencing and discussing negative emotions and following therapeutic guidance will aid in maximizing the benefits of our time together.

It's important to clarify that while our sessions may feel personal and are conducted in a congenial manner, our relationship remains strictly professional. Ethical guidelines prohibit harmful dual relationships or engagements that could compromise the therapeutic process (e.g., attending social events together, exchanging gifts, or connecting on social media). My primary aim is to safeguard the therapeutic environment out of genuine concern for your well-being.

Our initial session will focus on understanding the history and context of your current concerns. At the end of this appointment, I will discuss potential treatment plans with you, which may include ongoing psychotherapy, additional assessments, or referrals to other specialists. AtReef LLC provides both in-person and telehealth options to accommodate your needs and facilitate uninterrupted care. Assessments may be conducted as required for treatment planning. Like any effective treatment, psychotherapy comes with both benefits and possible risks, which will be discussed in detail.

The benefits of counseling will vary based on the treatment goals that you and I, Ehsan Adib Shabahang, LPC, establish. This process provides a platform to openly discuss your concerns with an impartial professional, possibly leading to improved mood and coping mechanisms. You may gain clarity on your personal goals and values and could experience increased life satisfaction. However, it's important to recognize that therapy also carries risks. Your challenges may initially worsen, or you may not achieve the expected outcomes. Emotional experiences could become intense, and on rare instances, new symptoms may emerge. Despite these possibilities, know that I am committed to supporting you to the best of my ability.

Consent and Privacy

As part of your treatment, I may request consent to use and disclose your protected health information for the purposes of treatment, payment, and healthcare operations. You may withdraw this consent at any time in writing, except where actions have already been taken based on it. For a detailed explanation of how your information will be used, please refer to the Notice of Privacy Practices for Protected Health Information. You have the right to review this Notice before providing consent.

Availability and Emergency Services

AtReef LLC does not offer emergency services. Non-urgent calls will be returned during regular business hours, usually on the same day, except for weekends and holidays. If you're in immediate need and can't wait for a callback, please go to the nearest emergency room or dial 911. You can also reach out to the 24-hour crisis hotline for immediate help.

Dog in Office

I may have my dog present during your visit. If you have allergies or find that a dog does not suit your therapeutic needs, please inform me, and the dog will be removed from the office. Although animal presence can offer therapeutic value, I understand that it may not be universally beneficial.

Conditions for Immediate Termination

I am fully committed to your well-being and progress. However, should there be a situation where I feel physically or emotionally unsafe, threatened, or violated, immediate termination of services may take place. Ethically, I might also initiate termination and offer an external referral if it's assessed that your treatment needs would be better met by another specialized professional.

Please note that if I don't hear back from you within 30 days regarding the continuation of services, your file will be closed and labeled as inactive. Feel free to reach out at any time to discuss the resumption of services.

Litigation Limitation

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.) neither you nor your attorney's, nor anyone else acting on your behalf will call your therapist or AtReef LLC to testify in court or at any proceeding nor will a disclosure of the psychotherapy records be requested.

General and Financial Policies

Professional Fees

In addition to regular therapy appointments and psychological assessment, other services may be provided to which AtReef LLC may apply a fee. Such services include: extended telephone conversations, consulting with other professionals, preparation of letters, or treatment summaries, etc. Individual therapy sessions (in-person or telehealth/web-based) are as listed online. They are subject to change and any shifts in fee structure will be discussed with all clients. Fees for longer sessions may be adjusted and fees are subject to change.

Financial Arrangements

You will be expected to pay for each session at the time that it is rendered, unless you have arranged another agreement with AtReef LLC. Accepted forms of payment include all major credit cards including HSA. If your account is overdue and you have not made payments or made a payment arrangement, AtReef LLC has the option of reporting you to a collection agency or the credit bureau. Additionally, future therapy sessions will not be scheduled until payment is received.

Cancellation Policy

Your appointment represents a valuable period of time that obligates the presence of you and your therapist. Should you need to change an appointment, please notify AtReef LLC at least 24 hours in advance, and please call if there is an emergency or other problem that prevents you from being at your appointment. If you fail to provide a 24-hour notification of your intent to cancel an appointment or if you miss an appointment without prior notification, other than in times of an emergency, you will be charged your session rate as the fee.

Credit Cards

AtReef LLC allows you the option of keeping your credit card on file to be charged for services rendered for your convenience and ease at check-in. When inputted into the system, the card information will be encrypted and securely stored so that your information will not be accessible to anyone. By signing below, you authorize AtReef LLC to charge this card for services rendered as well as for cancellation and no-show fees as outlined under the GENERAL AND FINANCIAL POLICIES. This credit card will also be used for all fees that have not been paid within 30 days. You will be provided a receipt for all payments upon request. You may revoke this agreement at any time by providing a request in writing.

I, the undersigned, voluntarily agree to participate in therapy, coaching, and/or assessment through AtReef LLC through in-person and/or online formats. I have read and fully understand the above practices to protect my privacy and understand that the Notice of Privacy Practices for use and disclosure of Protected Health Information (PHI) for treatment, payment and health care operations is available to me upon request. I understand the explanation of benefits that can be expected, possible risks that may occur, litigation limitation, and general as well as financial policies. I understand that my consent for services may be withdrawn at any time, and that I have the right to refuse to participate in any procedure which may be suggested, as well as the right to withdraw from counseling at any time.

Consent for Telehealth Consultation