New Client Paperwork – Santa Fe Victim Assistance Program

Service Expectations:

• Individual Counseling/Psychotherapy
  I understand that, in general, the goal of psychotherapy is to help me to learn to cope independently with stressful demands of life and/or remove obstacles to success or healthy relationships with others. Depending upon the needs of the individual, the duration of therapy varies. To ensure maximum effectiveness, my therapist and I will discuss the goals of therapy in early sessions and periodically review my progress thereafter.
• Family Counseling & Family Mediation
  I understand that the purpose of these services is to assist troubled relationships in identifying core issues in need of resolution and finding solutions that work for both/all people involved.
• Group Psychotherapy
  I understand that in group counseling, I learn to deal with issues through sharing with peers who are experiencing or have experienced similar issues and problems. We examine potential coping strategies, relational approaches, and support with one another under the supervision and facilitation of a counselor. I agree not to monopolize the time of the group or to criticize the way others deal with or avoid their issues, but to fully participate in giving them feedback and honest input as it is invited. I understand that I have much to learn from and to offer to others in my group. Therefore, my presence becomes important to others and I agree to remain prompt and consistent in my attendance. I understand it is not my responsibility to solve others' problems. I will remain supportive and present for others while working through their issues and can only expect the same from them.

In Any and All Modalities:

I am aware that in either mediation or counseling, that certain effects are possible in the short term before major progress is made because these processes open issues with which we are struggling before we can work toward solutions. Potential short-term symptoms include increased stress, emotional discomfort, and/or the disruption of current interpersonal and family relationships. Once goals are established and work begins in earnest, these effects typically subside rather quickly.

I have the right to terminate services at any time for any reason and understand that my provider or the front office can give referrals to other providers upon request.

It is strongly recommended that you discuss with your current provider any decision to terminate treatment or to switch to another provider. We do not mandate this, but we are all aware that it is important to have a good match between provider and client to enable our clients to accomplish their goals. Letting your provider know how he or she could better assist you may remedy the situation and/or assist him/her in the future with other clients who have your same preferences. Counseling is often a 'laboratory' for relationships in which you can try new approaches to relationships, communication, and/or conflict resolution techniques and build confidence in a nonjudgmental setting for important relationships outside the counseling setting. It is usually helpful for clients to learn to discuss difficult issues with their provider before attempting to address similar issues with others.

Appointments:

• Each individual & couple/family session is 50 minutes in length.

• My fee for each 50-minute psychotherapy session is stated below based on the licensure of my therapist.
• $175 for LPC, LPC-S, LMFT, LMFT-S
• $140 for LPC-Associate, LMFT-Associate
• $85 for Student Intern

Telehealth:

• Telehealth is the use of electronic means to treat the health, or in this specific case counseling or mediation, needs of clients at Innovative Alternatives, Inc. (IA). IA offers video and audio forms of communication via videoconferencing and telephone. This means the practice of behavioral & relational (family counseling or mediation) health care delivery, diagnosis, consultation, treatment, and education using interactive audio, video, or data communications, may occur from different locations geographically to assist with delivery of care when access to care is preferred or not possible by face-to-face visits.
• You understand that Telehealth at Innovative Alternatives, Inc. occurs in the state of Texas, and is governed by the laws of the state where the client resides. Telehealth is governed by the laws of the state in which the provider is located at the time of service delivery if that state is other than Texas. All IA providers are licensed in the state of Texas.
• While telehealth is an effective way to obtain care, if telehealth is determined as not in your best interests, your provider can explain these reasons to you and suggest alternatives better suited to your or your child’s needs. Examples of times when remote sessions are not considered best practice unless it is the only option available are during emergencies and/or when a child is not developmentally able to engage in talk therapy. By signing this consent, you agree in advance to seek emergency care if you or your provider deem it necessary. Before initiating telehealth, your provider will discuss an emergency response plan with you. IA and our providers may provide day-time consultation via phone or in person, and after-hours’ telephone coverage. Despite this, in the event of an imminent emergency, clients should consult the nearest emergency room or call 911 for emergent care.
• You, as the client, are responsible for information security on your phone or computer. If you elect to perform phone or video-conference therapy at home when others are present, it is imperative for best outcomes and confidentiality, that you are in a private room where others cannot hear even your end of the conversation—particularly if in any volatile relationships. If you decide to keep copies of emails or other communication with your provider on your computer, it’s up to you to keep that information secure. IA can encrypt emails from our end as they travel to your computer but cannot guarantee the security of emails as they travel from yours to ours. If you send anything from your employer’s equipment, your email legally belongs to your employer. It is possible, though unlikely, to intercept emails in transit. If you are concerned about this possibility, please consider encrypting emails with an encryption app. If an encrypted e-mail is intercepted, it is unreadable.
• Per HIPAA compliance, certain transmission vehicles (software) utilize the AES encryption which is one of the federal government's Federal Information Processing Standards (FIPS). Despite manufacturer representations, IA cannot independently certify that some software meets encryption criteria for HIPAA compliance. Therefore, by signing this consent, you release Innovative Alternatives, Inc. from any liability if you select the use of an application that is not secure and confidential as reported by a manufacturer. IA is aware that Microsoft Teams is secure and HIPAA compliant, and our agency prioritizes the use of this application. We also know that Skype, FaceTime, TikTok, and Live Chat are NOT HIPAA compliant or secure.
• You may receive remote sessions from home or work, if you are unavailable to come to the office, or if a provider is out of town, Additionally, you can utilize an office at Innovative Alternative, if you do not have equipment at home that allows remote sessions. The equipment needed for remote sessions via videoconferencing is (1) a device with a camera and sufficient audio; (2) internet access with a stable connection to prevent interruptions, and (3) arranging a location with sufficient lighting and privacy that is free from distractions and intrusions, and sufficient for privacy to protect your personal health information. IA can provide a guest computer for video-conference sessions with your provider when you do not have a private place otherwise or the requisite equipment otherwise.
• Please understand the risks and consequences of telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the Innovative Alternatives, Inc. and our providers, of virus infections, Trojan malware, and other intrusions with the potential to grab and release information you may desire to keep private. There is also the risk of others near you overhearing information if you do not take appropriate precautions in this regard. You maintain sole responsibility for ensuring the privacy of your surroundings if participating in telehealth from a location other than Innovative Alternatives, Inc. offices. Finally, you understand that with any form of psychotherapy, there are potential risks and benefits associated and that despite your provider’s efforts, your condition may not improve until the right treatment modality is applied for your issues or condition. In some cases, your mood may even seem to worsen as you open old wounds and/or grapple with difficult decisions you may have avoided examining for years.
• Payment for telehealth is determined in advance with IA. Many insurance companies reimburse for telehealth, although not all plans do so. IA does our best with sufficient time before your first appointment to verify your benefits. In any event, payment must be made before each session.
• At the start of each session, your provider is required to verify your identity and location as well as an accurate phone number to call you should connectivity be disrupted. Your provider will make 2 attempts to call that number after internet connectivity has been lost.
• Please understand that during a telehealth session it is possible to encounter a technological failure. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, your therapist will call you at the phone number you have indicated to complete your session. Please make sure you have that phone with you at the start of your session. You will need to answer your phone when the therapist calls after the video session is interrupted or you may be charged for the session. It may also be necessary to reschedule if there are other problems with connectivity.

Confidentiality:

The provider and Innovative Alternatives, Inc. follow all applicable laws, rules, regulations, guidelines, as well as codes of ethics and codes of conduct concerning privacy and those related to the client/therapist relationship in connection with psychotherapy and mediation sessions and the storage of records. Please remain aware, however, that there are exceptions to your expectation of privacy regarding psychotherapy or mediation sessions and the records documenting these sessions as well. Exceptions to confidentiality include situations where the provider is obligated by law to disclose information, including instances:

• Involving abuse or neglect of minors;
• Involving abuse, neglect, or exploitation of elderly or disabled persons;
• Involving abuse, neglect, illegal, unprofessional, or unethical conduct in an inpatient mental health facility, residential school, a chemical dependency treatment facility, a hospital providing comprehensive medical rehabilitation services, or of any client in nursing facilities;
• Involving sexual exploitation by a mental health service provider or mediator; involving a mental health or mediation service provider's improper conduct with a client which rises to the level of unethical practice according to the provider's governing licensing Board;
• When a client presents a danger to self or others in the best judgment of the provider; When a court orders the therapist or a District Attorney subpoenas disclosure of information or records (This exception is not applicable to mediation records, which are also protected from the court);
• When parents of a minor client request of information or records, unless such a release presents a danger or potential harm to the child or may have a negative influence on the child's mental or emotional state or create potential harm to the treatment relationship between child and provider. In such cases, Health & Human Service laws instruct providers to prepare a 'Treatment Summary' for parents which only discloses dates of service, whether the child is participating in treatment and whether child is making progress in treatment but is not required to relay any other content of the sessions with the child;
• When funding agencies audit Innovative Alternatives, Inc. or its programs (only possible for Victim Assistance Programs, but in almost 3 decades of service, client records were never requested from IA by this funding agency);
• When an insurance company, Employee Assistance Program, Crime Victim Compensation, or other third-party payer of any portion of your services request’s information;
• when you request your records or sign a 'Release of Information Form' asking us to disclose certain information to other physicians, employers, court, family members, or other medical or mental health or mediation service providers. Once the information is out of our hands, IA has no responsibility for securing your privacy after voluntary release by you as our client. If you wish to limit the scope of what is released, you must define which items we should release and items to keep confidential;
• When you voluntarily write a testimonial or consent to participate in research or evaluation activities conducted by IA. While information of this kind is always deidentified, recognition of your general story by others is beyond our control. It is best not to write such testimonials or to participate in research if you feel your circumstances are unique enough for recognition by persons who know you;
• When insurance, Ministry Assistance, or Employee Assistance Programs are utilized at IA; a client implicitly permits disclosure of medical/mental health/mediation billing records to the third-party payer for review. Certain insurance companies also require treatment providers to make treatment records available as requested (which is seldom done, but can happen), or to complete forms regarding treatment justifications when requesting extensions to the number of allowable sessions;
• Finally, you permit by signing this document to disclose billing information for unpaid invoices to a collection agency in the event of nonpayment of your account.

My signature below indicates that I am aware of the HIPAA Notice of Privacy Practice employed by Innovative Alternatives, Inc. I am also aware that at any time, I may receive a copy of the HIPAA Notice upon request or can review it in IA's office
or on the IA website at www.innovativealternatives.org

By signing below, you acknowledge your understanding that any expectation of privacy is limited, and that client/provider communications and therapist records are sometimes disclosed to third parties under the circumstances above. You also agree that the release of information regarding billing is always permitted to a third party paying for your services.

Treatment Team Approach:

By signing below, you are permitting discussion of your case with a program clinical supervisor and/or treatment team and billing staff within this agency. Innovative Alternatives, Inc. uses a treatment team approach to allow you, as our client, to gain benefit from the expertise of therapists and mediators you may never meet. Information is shared among staff treatment providers and clinical supervisors only as appropriate to ensure the highest professional quality and coordination of service.

Court Involvement of a Psychotherapist:

understand that IA charges for all time spent and all expenses incurred by a therapist or other representative of IA in responding to any subpoena, whether for an in-person court appearance, preparation of documents in my chart pertaining to me or my child, regardless of whether the subpoena was requested by me or by an attorney on my behalf. Services subject to billing include but are not limited to: time preparing for testimony, telephone contacts, review of any correspondence related to the case, review of records, duplication of records, waiting to testify and testifying, traveling, parking expenses and meals if at the courthouse during or adjacent to customary mealtimes.

I agree to provide a $1,500.00 advance retainer as soon as a subpoena is received by a therapist. Time is charged at an hourly rate of $175.00. All expenses are charged against the retainer as they are incurred. I agree to pay all such amounts promptly upon receipt of a phone call requesting payment via credit card from IA staff or receipt of a bill. I agree that waiting to inform the counselor until the last minute does not obligate this agency or the provider to go through extraordinary efforts to meet court deadlines. I am hereby informed that this is often a basis upon which this agency can file a 'motion to quash the subpoena for insufficient preparation time. I agree to work collaboratively and to strongly encourage my attorney to work cooperatively with IA and my provider for the benefit of my case and to prepare my provider adequately for court appearances.

IA agrees to prompt reimbursement of any unused portion of the advance retainer. I agree to make payment of court fees owed to IA regardless of the outcome of court proceedings and whether or not the testimony of the psychotherapist helps or hurts my case.

Policy Regarding Children:

• A parent or guardian must accompany all children less than fourteen years of age to appointments scheduled at Innovative Alternatives, Inc. The parent or guardian of a minor client must remain on the premises throughout the session. Children should use the restroom before the appointment. If a restroom break is needed during the session, it is the responsibility of the parent or guardian to assist and supervise the child.
• Innovative Alternatives, Inc. does NOT provide childcare at any time. It is the client's responsibility to provide adequate supervision of their children during their sessions. Due to limited waiting room space, parents and guardians should decide for childcare offsite during parent's scheduled sessions.
• If a parent and child are both scheduled at the same time by different providers, another adult must accompany the child to provide supervision in the waiting room if the child’s session ends before the parent’s, otherwise, staff must interrupt the parent’s session to supervise the child, even if the session did not start on time.
• Innovative Alternatives, Inc. is not responsible for children left unsupervised in the waiting room.
• Clients are responsible for the replacement of any property damaged by their children due to a lack of supervision.
• Please monitor your children in the waiting room so others are not disturbed by too much noise and/or activity. Please do not allow your children to ring the bell, run, or become loud. Others are dealing with serious life issues inside our walls. We reserve the right to ask you to leave if the children cannot remain well-behaved. If this is the case, you are still responsible for payment of the whole session even if you miss all or a portion of it for these reasons.
• We realize that some children are coming due to behavioral issues. The provider is responsible for behavior once the child is taken to the session, but if you cannot control them in the waiting room, we ask that you check-in and then wait outside in the courtyard until it is time for your session so others can concentrate on their therapeutic or relationship work.
• You have the option of attending my child’s sessions, but I understand the impact this may have on my child’s ability to form a clinical alliance with the provider, to have freedom of play and expression, and/or to make progress in counseling.

I agree that I have sole responsibility for my child while at Innovative Alternatives, Inc. I hold Innovative Alternatives, Inc. harmless for any consequence to my child on the premises or in the offices of Innovative Alternatives, Inc., and I agree to defend, indemnify and hold harmless Innovative Alternatives, Inc. and its employees for all damages caused by or suffered by me or my child while on the premises or in the offices of Innovative Alternatives, Inc., including, but not limited in any way too, all claims arising from the negligence, gross negligence, or strict liability of Innovative Alternatives, Inc. and/or its Landlord.

Grievance Procedure or Complaints against a Psychotherapist:

The relationship between the provider and the client is considered a professional one. The provider’s professional code of ethics prohibits any other relationship between the provider and the client while the professional relationship exists and extends for some time, thereafter, prohibiting any noncounseling activity initiated by either the provider or the client to establish a nontherapeutic relationship of any kind.

Direct all complaints against staff members who are not licensed or credentialed service providers, to the Office Manager, and if not satisfied with this response, to the President & CEO of IA or the Board of Directors if the complaint is against the CEO.

If you have a complaint against a licensed or credentialed provider of this agency, we ask that you follow this complaint procedure:

• Discuss the issue with your provider, if possible, and let them know how they can better meet your needs. All providers at IA are happy to help you find a good match and will not take offense if the issues are best addressed by a change in treatment provider.
• If the request for a new provider is based on more than simply match preference, please request another provider from the Intake personnel in the front office of IA. Please let us know what you felt the first provider did or did not do that made it difficult for you to do your work, so we can require more coaching or training and prevent future issues of the same sort for other clients. We are happy to arrange this time outside your session time without charge to you if preferred. Call or place your complaint in writing to the President & CEO of IA at 832-915-5020 or sbayus@innovativealternatives.org
• If this action is still not satisfactory, or the complaint is about the President & CEO, you may submit your complaint in writing to the Board of Directors of IA. Address your complaint to the Chair of the Board of Directors. The current Chair can be found by calling IA at 713-222-2525 or on our website at: www.innovativealternatives.org
• You may file an ethics complaint concerning a therapist, depending upon licensure, to:

Agreement of all Counseling Clients:

By signing below, I acknowledge that I have read, understood and agree to everything in this Agreement.

I authorize payment to Innovative Alternatives, Inc. I am voluntarily requesting the above service, and I agree to pay all charges submitted to me for that service or as provided in this Agreement. I also authorize Innovative Alternatives, Inc. to release any information necessary to process my insurance claims or billing to other agents.

Further, if the client is a minor child, I acknowledge, represent, and warrant that I have the legal right to agree to the services on behalf of the child named below.