Forms

The Couples Center Therapy Forms

Discernment Counseling Disclosures

The Couples Center: Discernment Counseling Disclosures

1. As a New Hampshire therapist, and a “Minnesota Couples On The Brink Project” trained clinician, please understand that I am not a lawyer, and do not provide legal advice. Please consult with an attorney or consult legal aid in your county if you have questions about the legal issues in your divorce.


2. In providing Discernment Counseling as a service, Susan Lager is not a part of the New Hampshire Judicial Branch. Participation in this process does not relieve participating parties from any obligations they may have in an ongoing divorce case. If you have initiated the legal divorce process, you may wish to to consider having your case placed on inactive status, or arranging a legal separation while you are working on reconciliation.


3. By participating in Discernment Counseling at The Couples Center, the parties agree that they will not seek to use in any court proceeding any statements made by the other party, or by Susan Lager. They also agree that they will not call as witnesses, or seek to obtain for court purposes any of the notes or documents prepared by Susan Lager.


4. Any information provided to Susan Lager by participants will remain confidential.


5. Susan Lager may wish to share couples’ stories of hope and change, without identifying information, in order to educate professionals and the public. Participants hereby grant permission for their story to be shared anonymously and without identifying information for educational purposes regarding Discernment Counseling. 


Susan Lager, LICSW

Non-Covered Service Information 

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WAIVER FORM FOR

  • NON-REFERRED SERVICE
  • NOT MEDICALLY NECESSARY SERVICE
  • EXPERIMENTAL/INVESTIGATIVE SERVICE

I. Provider Information

II. Patient Information

Patient ID#:

III.Waiver Form Statement and Provider Signature

The purpose of this waiver form is to inform Anthem Blue Cross and Blue Shield (Anthem BCBS) members, before they receive a medical service, that the service listed below is non-referred or not medically necessary or experimental/investigative. By signing this form, I, the provider acknowledge and agree that I have explained to the member that the service(s) listed are not a covered service(s).

IV. Reason for Waiver Form

HMO Members—Non-referred services are not covered by Anthem BCBS and, therefore, are the member’s responsibility.

Patient Signature


I have been informed by the provider indicated in Section I. in advance that the service(s) listed below are services that have not been referred by my primary care provider and are not covered. I understand and agree that I am responsible for payment of the provider’s charges for these services to the provider of service.

Not medically necessary and experimental/investigative services are not covered by Anthem BCBS and, therefore, are themember's responsibility.

Patient Signature


I have been informed by the provider indicated in Section I. in advance that the service(s) listed below are services that are not medically necessary or are services that are experimental/investi-gative and are not covered. I understand and agree that I am responsible for payment of the provider's charges for these services to the provider of service.

V. Service(s) To Be Provided

*If applicable

Intake Form

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Names:

Names:

Pursuant to the Regulations of the Board of Mental Health Practice in New VE Hampshire, all mental health professionals licensed by the Board must provide their clients with the following basic information. I encourage you to discuss any items with me if you have any questions:


Credentials

MSW - Fordham University Graduate School of Social Service, 1977 Portsmouth 

Certificate - Psychotherapy Institute, 1983

Certificate - Fowler Wainwright International Assoc. of Coaching, 2010 

Licensure -  New Hampshire, LICSW #202

Massachusetts, LICSW #105981

Certification - American Board of Examiners in Clinical Social Work, toush? "Board Certified Diplomate," (BCD) #14332


Professional Associations

National Association of Social Workers (NASW)

American Clinical Social Work Association (ACSWA)

American Association of Marriage and Family Therapists (AAMFT) Maine Association of Marriage and Family Therapists (MEAMFT) New Hampshire Psychological Association (NHPA)

Good Therapy.Org

International Association of Coaching (IAC)


Scope of Practice

I provide individual and couples therapy, specializing in couples therapy.

I provide Discernment Counseling to couples on the brink of divorce.

I provide consultation, coaching and training to individuals, couples and groups.

CouplespeakTM is a division of my practice which provides relationship tools and products live, and online.

I work with adolescents age 14 and older, and adults of all ages.

I do not provide any services to the following populations:

adult perpetrators of sexual abuse, violent offenders, or clients with active or untreated psychotic disorders.

 Supervision/Consultation

As part of maintaining a valid license, I am required to regularly discuss cases with colleagues for the purpose of addressing clinical issues which arise in the course of treatment, to broaden my perspective, and to maximize my clinical effectiveness and professional growth. I also obtain formal supervision on cases when I believe it is necessary. In these situations I do not disclose the identity of my clients. My colleagues, and any formal consultant are legally bound to confidentiality as well.

I also adhere to licensure requirements regarding continuing education to enhance and expand my clinical skills.


Code of Ethics

As a Licensed Independent Clinical Social Worker, I am governed by the Code of Ethics of the National Association of Social Workers (NASW). Copies of the Code are available at all times in my waiting room, and also available upon request.


Mental Health Bill of Rights

Pursuant to the N.H. Bill of Rights, clients have certain rights. A copy of the Mental Health Bill of Rights is posted in my waiting room. Please review it, and let me know if you have any questions. Copies are available upon request.


Conflicts of Interest

New Hampshire is a small state. From time to time, actual or potential conflicts of interest may arise. If I become aware of a potential conflict of interest in providing treatment to you, I may be required to refer you to another therapist. Regardless of the existence of a conflict of interest, you can be assured that any information will remain confidential.


Electronic Communications

Some insurance companies require that I, or my billing service send billing and other information by fax or email. I can't guarantee the confidentiality of this.

*If you do not consent to electronic communications, please inform me immediately before beginning treatment, so that I can determine whether and how to proceed. I do not accept or respond to electronic mail communications about treatment issues.


Confidentiality

Under New Hampshire law, communications between a client and a licensed psychotherapist are privileged (confidential), and may not be disclosed without the specific authorization of the client, except under specific, limited circumstances required by law. (For details refer to attached HIPAA privacy material).


Couples Therapy, Family Therapy, and Discernment Counseling

Information that is shared by a member of a couple or family cannot be considered confidential from the other parties in that therapy. Thus, there is no confidentiality between individuals in couples* or family treatment. Partners, by signing this, understand and agree that each will have access to the records of the other. Treatment of unmarried couples is not confidential between partners under New Hampshire law. Such treatment is the legal equivalent of group therapy, which is not privileged. Such couples agree, by signing this, not to disclose information to outside parties.


* Open Secrets Policy

In the course of couples therapy and Discernment Counseling, at intervals I meet with partners individually by request, circumstance, protocol, or clinical indication. Clients may share information with me that they may not have divulged to their partner for some compelling reason. Unless this information relates to the physical safety of the other, I will hold the "secret," and work with the individual to explore the issues around divulging it. My goal is to maximize honesty between partners. By signing this however, partners recognize that "secrets" may arise, agree to defer to my professional judgment about eventual disclosure or not, and agree to release me from any liability regarding any "secrets" I may hold.

Sanctity of Treatment

It is critical for partners engaged in couples work to feel as emotionally safe as possible with me and each other during the process. In order to preserve this safety I make it a policy, to the best of my ability, to stay out of any eventual legal proceedings between partners, (as in the case of separation or divorce). In my experience, it is not therapeutically sound to "wear two hats," or be in the role of psychotherapist, while positioning for a possible involvement in a legal process between partners. Furthermore, because of the systemic frame I embrace in viewing couples' problems, it would not benefit either partner for me to be drawn into any eventual legal proceedings exploring culpability for the decline of the marriage or partnership.

By signing this, partners agree to preserve the sanctity of the therapy, and not use the psychotherapy record, (even though they have the legal right to do so), in any possible future legal proceedings with each other.


Minors

The treatment of a minor must be authorized by a parent of the minor. Although communications between a client and a licensed psychotherapist are confidential, either parent of the minor, (even a non-custodial parent), has the right to access and authorize release of the psychotherapy record. When a child turns 18, the control of treatment, and treatment records reverts to the child.


Maintaining Professional Boundaries

Based upon my own ethics, professional ethics, and state law, I will maintain appropriate professional boundaries with current and past clients. New Hampshire state law requires that you, as a client, have the right to report inappropriate actions by any health-related professional to the Board of Examiners at (603) 226-3599. Please do not hesitate to raise any concerns you may have regarding this issue.

Limits of Availability and Emergency Coverage

My office hours vary based upon the time of year, and the scheduling needs of my clients. I am generally available for sessions Tuesdays through Fridays. Tuesday through Thursday: noon until 8:00 or 9:00 PM Friday: noon until 6:00 or 7:00 PM


I pick up voicemail messages periodically during the day and each evening, and can usually return a call within two days.


I utilize colleagues to share on-call coverage in my extended absence, I do NOT provide formal my emergency services. For emergencies requiring immediate attention, pleasent contact your doctor or local hospital emergency department. You may also call the Crisis Hotline in N.H. at (800) 273-TALK or in Maine at (207)282-6136.


Cost of Professional Services

(see Fee Policy on next page)


FEE POLICY

1. Couples Therapy  50 min: $175. Extended (75 min): $250.

*Prepayment for 10 sessions: 10% discount

Individual Therapy  50 min: $150.

*Prepayment for 10 sessions: 10% discount

Initial Consultation  90 min: $250. *Advance deposit required for reservation 

Discernment Counseling  2 hour initial: $325. Subsequent 90 Min. Sessions: $250.

Consultations: 60 min: $180.

Requested Paperwork  (letters, record prep, etc., 1 hr minimum): $125.

2. Payment options: I accept checks, cash, Visa, MC, Amex, Discover and debit cards.

3. Payment is expected at the time of service. A $20. charge will be applied for any returned checks.

4. Cancellation: All clients will be charged for missed appointments unless they CANCEL AT LEAST 48 HOURS IN ADVANCE. If there is a late notice of cancellation, but I am available for a rescheduled session at any time WITHIN THE SAME WEEK, no charge will be applied for the missed session.

5. Snow policy: Clients will be expected to attend sessions unless driving is hazardous, in which case no charge will be applied for late cancellations. Clients' discretion in assessing safety of road conditions will be honored.

6. Insurance: Clients are responsible for obtaining and tracking information regarding details of benefits, prior authorizations, deductibles, copays, timing of treatment reports to authorize more sessions, and to track balances. I am considered "out of network" for all managed-care plans except Anthem Blue Cross Blue Shield. (I will clarify those details upon request). *It is the client's responsibility to obtain prior authorization for psychotherapy (necessary for most plans). Many plans only authorize a handful of sessions unless the therapy is "medically necessary." Treatment reports are periodically required to document this, and to authorize more sessions. For all plans except Anthem BCBS I charge the above noted fee for this paperwork.

As insurance coverage for most therapy is limited, and usually unavailable for couples work, you will need to begin planning for the expense at the outset.

I encourage you to discuss any concerns regarding the use of insurance with me.

 

Recommended Treatment

At the beginning of the therapeutic relationship, and throughout your therapy, as appropriate, I will discuss with you my recommendations for treatment, as well as realistic expectations for change, and the possible costs and benefits which may accompany this process. You are encouraged at all times to ask any questions, and share any concerns you may have about our work together, or about the policies as stated above.


By signing this, you are acknowledging that you have read, understood, and agree to the above terms and policies of treatment with me.

Permission given for treatment of:

 

Authorization To Release Information


(Fill out if you are currently, or recently have been in therapy elsewhere, or are involved with other healthcare professionals.)

 

I (we) hereby authorize Susan Lager to share information with the following person(s) or facilities, concerning diagnosis, treatment, prognosis, and

recommendations, as well as other data pertinent to my (our) treatment, or that of my (our) child. This may be in the form of verbal discussions, or written reports, mailed or faxed.


I(we) also authorize the above named person(s) to discuss, or report in writing or fax to Ms. Lager any relevant history, treatment, diagnosis or similar information for the purpose of assisting with my (our) treatment, or the treatment of my child. I fully understand the nature of this information, and the authorization to release it is made voluntarily on my part. I understand that I may revoke this authorization at any time by written notice to Ms. Lager, but such revocation may not be retroactive. The expiration date of this authorization, if any, is:

Notice of Privacy Practices

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This notice details how your medical information may be used and/or disclosed, and how you may get access to this information. Please read it very carefully.


NOTICE OF PRIVACY PRACTICES


Privacy is an extremely important issue for all who come to this office. It is also complicated because of the many federal and state laws, as well as my own professional ethics. Because these rules have become so complicated, some parts of this Notice are quite detailed and you may have to read them several times before you have a clear understanding. If you have any questions, I will be happy to discuss these policies and your rights.


Contents of this Notice:

A. Introduction to my clients

B. What defines "medical information"

C. Privacy and the laws about privacy

D. How your protected health information may be used and shared

  1. Uses and disclosures with your consent a. Basic uses and disclosures for treatment, payment and health care operations (TPO) b. Other uses and disclosures in health care
  2. Uses and disclosures that require your authorization
  3. Uses and disclosures that do not require your authorization
  4. Uses and disclosures where you have an opportunity to object
  5. Accounting for disclosures we have made

E. Your rights concerning your health information

F. What to do if you have questions or problems

 

A. Introduction: To my clients

This Notice will give you specific details about how I handle your medical information. It describes how I use this information here in the office, how I may share it with other professionals and/or organizations, and how you can see the information. It is important to me that you know all of this so that you are able to make the most informed decisions for yourself and/or your family.


B. What defines "medical information"

Each time you visit this (or any other medical) office, hospital, clinic or are seen by a "healthcare provider", information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, laboratory tests, and/or treatment you receive from me or from others, or about payment for healthcare services. In terms of the law, the information that I collect from you is called PHI, which stands for Protected Health Information. This information goes into your medical chart, record or file in this office, and/or the offices of others by whom you may be treated.


In this office your PHI is likely to include these kinds of specifics:

  • Your history. As a child, in schend at work, marriage and personal history.
  • Reasons you came for treatment. Your problems, complaints, symptoms or needs:
  • Diagnosis, which is the medical terminology for your problems or symptoms.
  • A treatment plan, which is a list of treatments and other services which we think will help serve your best interest.
  • Progress or Clinical notes. These are the notes that I make about each of your visits; how you are doing, my observations and what you tell me.
  • Medication or pharmacological evaluation or status. This is the way 1 track the effects and/or progress of prescribed medications. (This may include medications you took or are taking.)
  • Records we may receive from others who have treated or evaluated you.
  • Laboratory test results, psychological test scores, school records and other such reports.
  • Legal matters.
  • Billing and/or insurance information.

(This list is fairly comprehensive, but there may be other kinds of information required to be kept in your healthcare records here in my office.)


I may use this information for a variety of purposes. For example:

  • To plan your care and/or treatment.
  • To evaluate how well my treatments are working for you.
  • If I speak with other healthcare professionals who are also treating you, such as your primary care physician, or the professional who referred you to me.
  • To document that you are actually receiving the services for which I am charging or billing you or your insurance company.
  • For teaching and/or training other healthcare professionals.
  • For medical or psychological research.
  • For public health officials trying to improve health care in this area of the country.
  • To improve the way I do my job by measuring the results of my work.

Understanding what is in your record and what it may be used for will enable you to make the best decisions about whom, when and why others might have this information. Although your healthcare record is the physical property of the healthcare provider or facility that collected it, the information belongs to you. You can read it, and if you want a copy, one may be made for you (a minimal fee will be charged to cover the cost of copying and/or mailing). If you find something in your records that you think is incorrect, or that something important is missing, you have the right to ask that the information be amended or changed. In some rare instances, I would not have to agree to do so. If you wish, I can explain this in greater detail.

C. Privacy and the laws about privacy

I am required to tell you about your privacy and related rights because of regulations created in a federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This law requires that I keep your Personal Health Information (PHI) private, and that I notify you of my legal duties and privacy policies and practices with this Notice of Privacy Practices (NPP). I will obey the rules of this notice as long as it is in effect, but if I change it, the rules of the new NPP will apply to all PHI that is in my possession. If] change the NPP, I will post the new notice in my office where it may be seen by anyone. You may request a copy of this notice.


D. How your protected health information (PHI) may be used or shared

When your information is read by me, or others in this office and used by us to make decisions about your care, that is called, in the law "use". If the information is shared with or sent to others outside this office, that is called. in the law "disclosure". Except in some special circumstances, when I use your PHI here in the office or disclose it to others, I share only the minimum necessary needed by those others to do their jobs. The law gives you the right to know about your PHI, how it is used, and to have a say in how it is disclosed (shared). The following information will explain in some detail what I might do with your information.


I use and disclose PHI for a variety of reasons, in a variety of ways. For some uses, I am required to tell you about them and have a written authorization to do so. In other uses, the law allows disclosure without your authorization. These are spelled out below.


1. Uses and disclosures of PH in healthcare with your consent.

After you read this Notice, you will be asked to sign a separate Consent Form to allow me to use and share your PHI. In almost all cases, I intend to use your PHI here or share your PHI with other people or organizations to provide treatment for you, arrange payment for your services, or some other business called healthcare operations. Together, these routine purposes are referred to as TPO, and the Consent Form allows us to use and disclose your PHI for TPO. I know this is a bit confusing, but please read carefully as it is very important.


1 a. Basic uses and disclosures for Treatment, Payment or Healthcare Operations - TPO 

I need information about you and your condition in order to provide treatment for you. You have to agree to let me collect the information, use and/or share it, to care for you properly. Therefore, you must sign the Consent form before I begin treatment, because it you do not, I cannot treat you. 


In most cases, when you come to see me, I will be the only one who will collect information from you, and put it in your healthcare records here. In some circumstance, and only with your prior agreement, you may meet jointly with another professional, in order to address specific goals, problems or issues. This person(s) would be a professional associate, who is bound by contract with me to safeguard the privacy of any information which you agree to share with them. Generally, I may use or disclose your PHI for three purposes: treatment, obtaining payment or healthcare operations.


Treatment: I use your medical information to provide you with psychological treatments or services. These might include individual, couples, family, or group therapy, treatment planning. or measuring the benefits of our services.


I may disclose your PHI to others who provide treatment to you, such as your personal physician. If you are treated by a team, I can share some of your PHI with them. Other professionals treating you may verbally or in writing, give me information about their findings, the actions they took, and their treatment recommendations, so that we can all decide what works best for you and make up a Treatment Plan. In cases where you may require additional services I am unable to provide, 1 may refer you to other professionals or consultants. When I do this, I will need to tell them some things about you and your conditions. We will get back their findings and opinions and those will go into  your records here. If you receive treatment in the future from other professionals, I may also share your PHI with them.

Payment: I may use your information to bill you, your insurance or others so that I may be paid for the treatment services I provide to you. I may contact your insurance company to check on exactly what your insurance covers. I may have to tell them about your diagnoses, what treatments you have received, and the changes I expect in your condition(s). I will need to tell them when we meet, your progress and other similar things.


Healthcare Operations: I may use your PHI to see where I can may improvements in the care and services I provide. I may be required to supply some information to some government health agencies who may be studying disorders and treatments, and/or making plans for services that are needed. If I do this, your name and personal information will be deleted from what I send.


1 b. Other uses in Healthcare:

Appointment Reminders: I may use and disclose your PHI to reschedule or remind you of appointments for treatment or other care. If you want me to call or write to you only at your home or your place of work, or some other place, I can usually arrange that. You will need to let me know which you prefer.


Treatment Alternatives:   I may use or disclose your PHI to tell you about or recommend possible treatments or alternatives that may help you.


Other Benefits and Services:   I may use or disclose your PHI to tell you about health-related benefits or services that may be of interest to you.


Research:   I may use or share your PHI to do research in order to improve treatments. For example, comparing two treatments for the same disorder to see which works better, faster and/or costs less. In all cases, your name, address and other personal information will be removed from the information given to any researchers. If they need to know who you are, I will discuss the project with you and you will have the right to decide whether or not you wish to share the information, and will sign a written authorization if you chose to disclose.


Business Associates:   There are some jobs I hire other business or people to do for me. In the law, they are called Business Associates. An example of this might be a billing service that I hire to process the billing portion of my business. Business Associates would need to receive some of your PHI to do their jobs properly. 10 protect your privacy, they are bound by a contract with me, to safeguard the privacy of your information.


2. Uses and disclosures that require authorization.

If I want to use your information for any purposes besides the TPO or those described above, I need your permission on an Authorization form. I do not expect to need this in most cases.


If you do authorize me to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time, I will not use or disclose your information for the purposes we have agreed to. Of course, I cannot take back any information that I may have already disclosed with your permission, or that I had used in my office.


3. Uses and disclosures of PHI from mental health records that do not require consent or authorization. 

The law allows me to use and disclose some of your PHI without your express consent in some very specific instances, which are detailed as follows:

Mandated disclosures:

Some federal, state or local laws require me to disclose PHI if l:

  • I become aware of, or suspect child abuse.
  • If you are involved in a lawsuit or legal proceeding, and I receive a subpoena, discovery request, or other lawful process, 1 may have, to release some of your PHI. 1 win only do so after trying to inform you of the request, consulting your attorney, or trying to get a court order to protect the information that is requested.
  • I have to disclose some information to government agencies which may check to see that I am obeying privacy laws.

Law Enforcement Purposes:

I may have to release medical information if asked to do so by a law enforcement official who is investigating a crime or criminal.


Public Health Activities:

I may have to release medical information to agencies which investigate diseases of injuries.


Relating to Decedents:

I may have to disclose PHI to coroners, medical examiners or funeral directors, and/or to organizations relating to organ, eye or tissue donations or transplants.


For Specific Government Functions:

I may have to disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment. I may be required to disclose some of your PHI to Workers Compensation or Disability programs, to correctional facilities if you are an inmate, or for national security reasons.


To Prevent a Serious Threat to Health or Safety:

If I come to believe that there is a serious threat to your health or safety, or that of any other person, public or property, I must disclose some of your PHI. I will only do this to persons who can prevent the danger.


4. Uses and Disclosures where you have an opportunity to object:

I may share some information about you with your family or close others. I will only do so if those people are involved in your care, and with anyone you might choose, such as close friends or clergy. I will ask you about who you want me to tell what information about your condition or treatment. You can tell me what you want and I must honor your wishes as long as it not against the law, and that I believe it is in your best interest.


If it is an emergency where I cannot ask if you disagree, I can share information if I believe that it is what you would have wanted, and I believe that it will help for me to do so. If I do share information in an emergency situation, I will tell you as soon as I can. If you don't approve, I will stop, as long as it is not against the law.


5. Accounting of Disclosures:

When I disclose your PHI, I may keep records of who I sent it to, when I sent it, and what 1 sent. You are entitled to receive an accounting (or list) of many of these disclosures.


E. Your Rights Concerning Your Health Care and Related Information:

In my office, there is posted a Mental Health Bill of Rights which specifically details all rights to which you are entitled by state and federal laws. If you would like a copy of this, you may ask for one.

 F. What To Do if You Have Questions or Problems

If you need more information, or have questions about the privacy practices detailed above, please speak with me. If you have a problem with how your PHI has been handled, or have concerns about violation of your privacy, please contact me immediately. My number and address are listed at the beginning of this notice and below. You also have the right to file a complaint with me, and/or with the Secretary of the Federal Department of Health and Human Services. I promise that I will not in any way limit your care or take any actions against you if you complain.


I may be contacted by mail at Portside Office Suites 19 Bridge Street - Unit 9 Kittery, ME 03904, or by telephone at (603) 431-7131.


The effective date of this notice is October 1, 2004.


Susan Lager LICSW, BCD

Consent to Use and / or Disclose your Health Information


When I examine, diagnose, treat or refer you, I will be collecting what the law calls Protected Health Information (PHI) about you. I need to use this information in my office to decide what treatment is best and to provide appropriate healthcare. I may also need to share this information with others who provide treatment for you, or need to mange payment for your treatment or for other business functions.


By signing this form you are agreeing to let me use your information here, and/or to share it with necessary others. The Notice of Privacy Practices explains all your rights in more detail, as well as how I can use/share your information.


If you do not sign this consent form agreeing with what is in the Notice of Privacy Practices, I will be unable to treat (or continue treating) you.


In the future it may be necessary for me to change how I use and share PHI, and so may change my Notice of Privacy Practices. If I do change it, you will be notified, and will be able to get a copy of the new notice by contacting me at the phone or address above.


If you have concerns about some of your information, you have the right to ask me not to use or share some of the information for treatment, payment, or administrative purposes. and will need to indicate your wishes in writing. Although I will always try to respect your wishes, I am not required to agree to these limitations. However, if I do agree. I promise to comply with your wishes.

After you have signed this consent, you have the right to revoke it at any time by written notice to me, and I will comply with your wishes about using or sharing your PHI from that time forward. Depending upon the limitations you request. I may have to stop treat- ment at that time, and I may have already used or shared some of your information.

REMOTE SESSIONS: PHONE, ONLINE VIDEO AND CONFERENCE CALLS

There are times when it is necessary or indicated to use a call or online video instead of having a live, face-to-face session:

  • During bad weather when it might feel unsafe or uncomfortable to drive
  • When you're out of town, or unable to come to the office, had an emergency, or don't feel well enough to travel, but want a session.
  • For coaching clients where the primary format is via phone.
  • When some situation has precluded my ability to make an office session
  • For clients requiring private access to treatment without risk of any public exposure.


THERE ARE A FEW DIFFERENT OPTIONS FOR REMOTE SESSIONS:

  1. Arrange a call with me at a set time, and I'll call you.
  2. Schedule an individual or couples online video session with me on the Psychology Today site. It's a free, secure, HIPPAA secure service available to anyone with a computer. You can transmit from different locations. Log on at: https://sessions.psychologytoday.com/susanlager
  3. Schedule a conference call with me via a landline or cellphone. This can be used when more than two of us will be on the call, or callers will be coming on from different locations.

Dial in number: (605) 475-4800

Access code: 565515#


Payment:

When you call in, provide information about the credit or debit card you'd like to use. I'll then process it through the Square app on my phone and send you a text or email receipt.

Social Media and Internet Boundary Policies

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Since some of my therapy practice is based online, there are some unique challenges that come up that are important to be aware of prior to starting this form of treatment with me. Please read this document in order to understand the expectations of the client and the therapist while interacting online.


Interacting on social media and the Internet with clients can compromise your confidentiality, can blur the boundaries of our therapeutic and professional relationship, and can impact our working relationship. My primary concern is your privacy, and engaging in social media with you could compromise your privacy without my knowledge.


If there are things from your online life that you would like to share with me, please bring them to our sessions. We can review and explore them together during our therapy time. Here are a few policies about social media and Internet boundaries that I would like you to review:


Friending

I do not accept friend requests from current or former clients on any social media sites (including, but not limited to: Facebook, Twitter, Linked In, Snapchat, Instagram, etc.)


Following

If you use an easily recognizable name on Twitter or blog commentaries, and you decide you want to follow my professional stream of tweets or blogs, we may discuss this and its impact on our therapeutic relationship. If you choose to follow me, please note that I will not follow you back due to privacy concerns and appropriate professional boundaries.


"Googling" and Use of Search Engines

It is not part of my regular practice to search for clients on the Internet using Google, Facebook, or other search engines. Extremely rare exceptions may be made during times of crisis (i.e.: if I have reason to believe that you are in danger and you have not been in touch with me via our usual means).

Location-Based Services

There are some privacy considerations if you are using location-based services on your mobile device. Keep in mind that using a location-based service on your mobile device (even if you are unaware of it being activated) could violate your confidentiality and privacy.


Review Sites

You may find my practice on various review sites such as Yelp, Healthgrades, Google Business, or other places that list businesses. Some of these sites have review options that allow users to rate their experience. According to Kolmes (2010), many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site.

If you should find my listing on any of these sites, please know that my listing is not a request for a testimonial, rating, review, etc. While you have the right to express yourself on any site you want to, due to confidentiality concerns, I cannot respond to any review on any of these sites whether it is positive or negative. Because of privacy concerns, it is also likely that I will never see these sites and I ask that you discuss with me your feelings and reviews of our work directly instead, as this can be an important part of our therapeutic relationship.


Communication

Please use email to communicate with me on the Internet. You may feel free at any time to call my confidential voicemail as well. I recommend this method, as it is more secure.

Any messages you send me will be part of your medical record. Please note that I may not respond to emails and voicemails immediately if they are not an emergency or if I am in session or out of the office.


Appropriate Boundaries

Utilizing the Internet as a way to communicate can often arise some boundary issues that are not present in traditional face-to-face therapeutic relationships. Clients often feel free to express themselves in more open and deeper ways in a distance therapy situation. Clients can utilize telephone, chat, and video conferencing sessions in order to express more intimate and complex thoughts, feelings, and behaviors. Because inappropriate and compulsive behavior on the Internet is often one of the issues clients struggle with in their regular life, it can often be an issue within the therapeutic relationship. Please keep in mind that all medical records and any inappropriate communication will be documented and addressed by the therapist in session.

These policies have been developed in order to protect your privacy and keep our therapeutic and professional relationship confidential. Please feel free to bring up any questions or concerns you have regarding the information found in this document when we have a session. As new technology, apps, programs, and resources develop and as the Internet changes, it may be necessary for this document to be updated. If this document is updated, I will notify you and send you a copy of the updated policy.

This document was adapted Dr. Keely Kolmes "My Private Practice Social Media Policy" document.


Tele-Therapy and Electronic Therapy (E-Therapy) Informed Consent Form


By signing below, I consent to engaging in tele-therapy and/or electronic therapy with Susan Lager LICSW, as part of my mental health treatment. I understand that "tele-therapy" and "electronic therapy" includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications such as the telephone, cellular phones, the Internet, and various programs such as iChat, VSee, and other relevant programs. I understand that I have the following rights with respect to tele-therapy and/or electronic therapy:

  •  I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
  • The laws that protect the confidentiality of my health information also apply to tele-therapy and electronic therapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination or personally identifiable images or information from the tele-therapy and/or electronic therapy interaction to other entities won't occur without my written consent.
  • I understand that there are risks and consequences from tele-therapy and electronic therapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my health information could be disrupted or distorted by technical failures; the transmission of my health information could be interrupted by unauthorized persons; and/or the electronic storage of my health information could be accessed by unauthorized persons. I also understand that the programs listed above have their own policies that might interfere with confidentiality and I am fully aware of the risks associated with working with these programs. In addition, I understand that tele-therapy and electronic therapy based services and care may not be as complete as face-to-face services. I also understand that if my therapist believes I would be better served by another form of psychological services (e.g. face-to-face services) I will be advised about this by my therapist, and we will proceed that way, or if not logistically feasible, I will be referred to another therapist in my area with whom I can do that form of work. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases may even get worse.
  • I understand that tele-therapy and electronic therapy is not the recommended modality of treatment for many clients including, but not limited to: clients who are actively suicidal or homicidal, clients with severe psychiatric conditions, clients in violent situations, etc. I understand that if I am identified as falling into the previous categories, or others, that I will be offered a referral to another therapist who utilizes a modality that will be better suited to my needs.
  • I understand that I may benefit from tele-therapy and/or electronic therapy, but that results cannot be guaranteed or assured.
  •  I understand that I have a right to access my health information and copies of records in accordance with state law.

Permission for the Use of Email

Contact Us

Before scheduling the initial session with clients I am required to provide "Informed Consent" intake materials for clients to review and sign, acknowledging their understanding of my policies and practices. In these packets I also need to gather certain information about clients - their contact information, current relationship and family status, relevant medical and psychotherapy history, etc. It is most convenient and expedient for the majority of clients to receive these materials by email, rather than to wait for mailed copies, or to fill them out in person, half an hour in advance of their initial session.


It is also more convenient for many clients to exchange information via email with me about scheduling appointments, than to call my confidential voicemail, even though I recommend the latter. (603)431-7131


I do NOT however, recommend that clients send me any detailed emails regarding their confidential treatment issues, as email is not always a secure form of communication. I advise clients to reserve those communications for therapy sessions, or, prior to the first session, through our phone contact.


By signing this form, you individually, or with your partner, are agreeing to the exchange of emails with me for the above informational purposes.

 

agree to the exchange of Email with Susan Lager LICSW, at her Email address: Couplesctr@gmail.com

Have a question about one of our forms? Call (603) 431-7131 today to speak with Susan.

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