Informed Consent- Sharing is Healing
Before the initiation of services you as the client or as the guardian/representative of the client will be asked to read and sign this informed consent statement. To initiate psychotherapy services, you must be at least 18 years old or an emancipated adolescent. If you are a minor client or a dependent adult, your guardian/representative will need to consent for treatment and you will be provided with the information included in the informed consent materials and asked for assent. Adult clients or the guardians/representatives of clients will be asked to complete the informed consent document stating that you/they have read, understand, and agree to the conditions stated within before therapy will commence. There is also a Patient Bill of Rights you will be asked to read and confirm understanding. If you have any questions about these documents, please discuss them with your therapist.
Full Name: *
Date of Birth *
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Cell phone Number: *
SERVICES:
You are eligible for counseling services, assessment, and/or referral consultation services from Sharing is Healing.
In Person SESSION FEES:
Your initial session when your full history is gathered is $170. Charges for individual sessions are $150 and group charge of $55 per session. All out of pocket fees, including any co-pays or deductibles, are due at the time of your session. Individuals, without accepted insurance, who would benefit from a discounted fee may submit a "request for discounted rate form" bringing rates to: $100 initial session , $75 per individual session and $35 per group session.
INSURANCE:
Although your BCBS or Midland’s Choice Health insurance MAY cover all your fees, ultimately it is your responsibility to cover all your costs. Some plans require preauthorization before your first visit. It is YOUR responsibility to obtain this authorization. Mental Health benefits may differ from your medical benefits so it is essential that you have researched your mental health benefits prior to your visit. If you have not done this prior to your visit, and/or your treatment is not a payable benefit, you will be responsible for the full cash payment rate, billed to insurance, at the time of service. Further, if your insurance carrier determines that the services received are not medically necessary, you will be responsible for full payment of your accrued fees.
CONSULTATION FEES:
-There may be occasions when clients are not able to meet with Michelle in person as they typically do; however, touching base may be helpful. Any phone consultations or on line consultation meetings are not billable to insurance.
50 minutes: $75
30 minutes: $40
- Due to the complexity of treatment of eating disorders and some other mental health issues there may be additional administrative fees accrued based on consultation with other treatment team members and the need for outside of session contact (e-mails/texts/calls…) between you and myself. These fees will be discussed in detail with you prior to being charged to determine specifics for your care.
ON-LINE SERVICE FEES & INFORMATION:

Initial intake meeting: $100
Individual 50-minute meetings: $75
Group meetings: $50
Workshop meetings: $25

You as the client understand that phone and online sessions are unique compared to in-person sessions, among differences being the lack of “personal” face-to- face interactions, the lack of visual and audio cues in the therapy process, and the fact that most insurance companies will not cover this type of therapy. You understand that online and telephone therapy may not be appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room. You also understand that I follow the laws and professional regulations of the State of Iowa(USA) and the psychotherapy treatment will be considered to take place in the state of Iowa (USA).

LATE CANCELATION/NO SHOW FEES (in person & on line):
An appointment missed without cancellation and appointments cancelled within 24 hours, will result in a no show/late cancel fee whether scheduled for in session or online:

Individual sessions:
-Monday-Friday 7 a.m.-5 p.m. $100
-Evening appointments after 5 p.m. & appointments on Saturday & Sunday $150

Group sessions:
-Monday-Friday 7 a.m.-5 p.m. $40
-Evening appointments after 5 p.m. & appointments on Saturday & Sunday $50

PRIVACY OF INFORMATION:
Both professional ethics and the law require strict procedures to keep your information confidential. If you are 18 years of age or older, all information you share at Sharing is Healing is privileged and treated confidentially according to state and federal law. The law requires that I obtain your signature acknowledging that I have provided you with this information. Michelle will not release personally identifiable information without your prior written permission. There are some situations, however, in which she may legally and ethically be obligated to release counseling information, even without your consent. These include:
•Situations in which there is a clear and present danger that someone's life, health or safety is at risk.
•Cases of apparent abuse of a child or a dependent adult.
•Other situations required by state or federal law, such as subpoenas and court orders.

If you are under 18, you and Michelle will discuss communication of information with your guardians

• Disclosures required by health insurers or to collect overdue fees.
• You should be aware that Sharing is Healing may need to share protected information with other professionals/partners for clinical/scheduling/billing issues. All these individuals have singed a HIPPA business agreement form agreeing to protect your private information and comply with all HIPPA guidelines.
• If you file a complaint against Sharing is Healing I may disclose relevant information in order to establish any necessary defense/response.

As seriously as Sharing is Healing holds your information, I ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, if more than half of your session time remains, email to schedule a new session time.

Communicating with parent(s) or guardian(s):
Except for situations such as those mentioned above, therapists will not tell parents or guardians specific things shared in private therapy sessions. This includes activities and behavior that parents/guardians may not approve of — or would be upset by — but that do not put the child at risk of serious and immediate harm. However, if their risk-taking behavior becomes more serious, then the therapist will need to use their professional judgment to decide whether the child/teen is in serious and immediate danger of being harmed. If the therapist feels that the client is in such danger, they will communicate this information to the parent or guardian.

Even if the therapist has agreed to keep information confidential – to not tell the parent or guardian – the therapist may believe that it is important for them to know what is going on in the child/teen’s life. In these situations, the therapist will encourage the child/teen to tell their parent/guardian and will help find the best way to tell them. Also, when meeting with parents, the therapist may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to their child/teen.

Children/teens/dependent adults with guardians should also know that, by law in Iowa, the parent/guardian has the right to see any written records kept about sessions. It is extremely rare that a parent/guardian would ever request to look at these records and we ask parents/guardians to respect their child’s confidentiality to promote the goals of psychotherapy.

Social Media & Electronic Communication Policy
Social Media and electronic communication may NOT be used to access crisis services!
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages.
I am ethically and legally obligated to maintain records of each time we meet, talk on the phone, or correspond via electronic communication such as email or text messaging. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. A judge can subpoena your records for a variety of reasons, and if this happens, I must comply.


Separate Accounts

Michelle holds separate and isolated accounts to be used for the sole purpose of professional matters regarding Sharing is Healing. These accounts are separate from any personal accounts held by Michelle Roling as an individual.

Email

Email communication is not completely secure or confidential. Any emails I receive from you and any responses I send to you become a part of your legal record. It may be helpful for you to update Michelle via email. Please know, most communication will not be responded to and will be discussed at subsequent sessions. You are also advised that any email sent to me via computer in a work-place environment is legally accessible by an employer. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. As a reminder, I cannot guarantee immediate response and request that you do not use these methods of communication to request assistance for emergencies.


Text Messages

Texting updates to Michelle may be helpful for you, please know, I will not respond to texting; information will be discussed at subsequent sessions. Any text message I receive from you becomes a part of your legal record. As a reminder, I cannot guarantee immediate response and request that you do not use these methods of communication to request assistance for emergencies.


Friending

I do not accept friend or contact requests from current or former clients (prior to 7 years of time passing) on any social networking site (Facebook, LinkedIn, etc.). Adding clients as friends on these sites can compromise your confidentiality and our therapeutic relationship.

Following

I will not follow any client on Twitter, Instagram, blogs, or other apps/websites. If there is content you wish to share from your online life, please bring it into our sessions where we can explore it together.

Search Engines

It is not a regular part of my practice to search for clients on Google, Facebook, or other searchable sites. An exception could be during a crisis. If I have reason to suspect you are a danger to yourself or others and I have exhausted all other reasonable means to contact you and/or your emergency contact, then I may use a search engine for information to ensure your welfare. If this ever occurs, I will fully document the search and discuss it with you at your next session.

Location-Based Services

Please be aware if you use location-based services on your mobile phone you may compromise your privacy while attending session at my office. My office is not a check-in location on various sites such as Foursquare, however it can be found as a Google location. Enabled GPS tracking makes it possible for others to surmise you are a counseling client due to regular check-ins at my office location

By selecting the box below, I acknowledge understanding and acceptance of this policy. *
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RISKS ASSOCIATED WITH COUNSELING:
Psychotherapy is considered to be a safe and effective treatment for a wide range of mental health concerns. Some of the benefits include reduction of symptoms, development of coping and problem solving skills, providing support during intense emotional times, and facilitating the creation of healthier relationships. Risks can include initial and temporary increases in emotional tension or discomfort. Changes during therapy may occur that affect relationships. If these become too distressing; please discuss them with your therapist.

Alternatives to psychotherapy include no treatment or medication therapy. Medication may be an option for assistance with managing the physiological/medical problems associated with mental health concerns and used in conjunction with therapy. The therapist you work with can assist you with a referral for a medical or psychiatric consultation if needed

Professional Consultation:
Professional consultation is an important component of a healthy psychotherapy practice. As such, therapists regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, therapists will not reveal any personally identifying information regarding clients.
Client Litigation
Therapists will not voluntarily participate in any litigation, or custody dispute in which a Client or their Representative/Guardian and another individual, or entity, are parties. Michelle has a policy of not communicating with Representative’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Client’s, or Representative’s legal matters unless clients complete a written release of information form or the information is court ordered by a judge. Therapists will generally not provide records or testimony unless compelled to do so. Should therapists be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving a client, the client will be contacted immediately. Clients agree to reimburse the therapist for any time spent for preparation, travel, or other time in which therapist has made herself/himself available for such an appearance at therapist’s usual and customary hourly rate. In addition, the therapist will not make any recommendation as to custody or visitation regarding clients.
Termination of Services:
Clients and therapists may mutually agree to termination of therapy when treatment goals are met. The therapist reserves the right to terminate therapy at her discretion. Reasons for termination include, but are not limited to; successful completion of therapy goals, non-attended sessions, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, if client needs are outside of the therapist’s scope of competence or practice, or if the client is not making adequate progress in therapy. The client or her/his/their representative/guardian has the right to terminate therapy at her/his discretion. Upon either party’s decision to terminate therapy, the therapist will generally recommend that client participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done and make appropriate recommendations if needed. Therapists will also attempt to ensure a smooth transition to another therapist by offering referrals to the client or their guardian(s) and offer consultation.
By selecting the check box below, I agree:
I have read and understand the information presented above.
I voluntarily consent to assessment and/or treatment at Sharing is Healing.
I will abide by the terms stated above.
I agree to all above information *
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HIPPA Agreement/Client Bill of Rights
I verify that I have been provided with a written informed consent for psychological services- including written information regarding risks and benefits of services, limitations of confidentiality & informed about my rights and responsibilities as a client, along with a written Notice of Privacy Rights under HIPPA and a general statement about consumer rights. I understand that Sharing is Healing; Michelle Roling is willing to answer any questions I may have about these written documents.
I agree to all above information *
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