Informed Consent for Journey Into Wellness Counseling

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Julie Wells LCSW, CP, TEP 26133 US Hwy 19 N #306 Clearwater, FL 33763
(727) 688-5800 journeywellness@aol.com

PO Box 464 Crystal Beach, FL 34681 Fax (727) 286-9640

NPI 1558675603 FLSW9966

APPOINTMENTS AND AVAILABILITY

Services are scheduled by appointment. Fees are $150 per clinical hour; $180 for the initial assessments.

If my insurance is in-network with this provider, my insurance payments will be accepted as payment and I will only owe any co-payments or deductibles due.

I will verify and confirm my insurance benefits prior to our first visit, annually, and if there are any changes to my coverage.

A fee of $150 will be charged to my credit card on file for missed appointments or those canceled with less than 24 hours' notice. Cancellation and no-show fees are not reimbursable by insurance and are the client’s responsibility.

I will be charged on the morning of the appointment, not after services are provided.

A clinical hour is just over 50+ minutes and that allows time to set our next appointment, etc.

To maximize benefit, I will arrive on time as much as possible.

If I have not been seen in this office in 90 days, my file will be moved to inactive.

I have read, understand, and agree

Required

INSURANCE VERIFICATION AND RESPONSIBILITY
I understand that while this office may assist in verifying my insurance coverage, it is my responsibility to confirm that I have active mental health benefits and to inform the provider of any changes. Insurance companies may deny claims retroactively or request repayment after initially paying for services. In such cases, I understand that I am financially responsible for those services and agree to pay the full session fee if reimbursement is denied or retracted.

Cancellation and no-show fees are not reimbursable by insurance and are the client’s responsibility.

I have read, understand, and agree

Required

Please check that you understand each *

I am a competent adult voluntarily seeking mental health assessment and/or counseling for myself and/or my minor child.

I understand that, although mental health counseling is expected to be helpful in resolving my problems, no guarantee has been made about the usefulness or effectiveness of treatment.

Required

COORDINATION OF CARE WITH YOUR PRIMARY CARE PROVIDER (PCP)

I believe coordination between your therapist and your Primary Care Provider (PCP) supports safe, effective care. I request your permission to contact your PCP to share relevant information about your treatment.

This may include diagnosis, medications, progress, or health concerns.

If you consent, you may revoke this permission at any time in writing.

If you do not consent, your decision will be documented and honored. Your care here will not be affected.

Yes, I authorize my therapist to contact my PCP and share relevant treatment information.

No, I do not authorize contact with my PCP. I understand this refusal will be documented in my record.

Clear selection

Primary Care Physician (PCP) Name (whether I can contact them or not, this is for your record)

PCP Phone/Fax (if known)

FEE AGREEMENT AND CANCELLATIONS

The fee is $150 per session. These fees are set in accordance with the usual and customary charges given credentials and experience. Fees are subject to change. Clients will be notified in writing at least 30 days in advance of any rate increases.

I understand that full payment must be made in either check, cash, or credit card through IVY Pay at time the services are rendered. A link will be sent prior to the first session and must be completed BEFORE OUR VISIT.

Co-payment is due at the time of service unless other arrangements are made in advance (or full payment, if insurance is not used or deductible is not satisfied). Receipts will be provided upon request to allow reimbursement with HSA or insurance provider.

I understand that if insurance does not pay for my treatment—whether due to deductible, coverage limits, changes in plan status, or retroactive denial—I am financially responsible for the full fee. I acknowledge that insurance plans can retroactively terminate coverage, and in such cases, I agree to pay for services already provided, even if the insurer initially approved and paid for them.

I am aware that I need to cancel any appointments at least 24 hours in advance or I will be charged the full session fee ($150) for the missed appointment. It is assumed that without a phone call, if I am more than 15 minutes late for a session that I will not be attending.

I understand that full payment for my FIRST initial assessment appointment must be made before reserving my initial appointment.

I have read, understand, and agree

Required

PRIVACY & SOCIAL MEDIA/TEXT/TECHNOLOGY POLICY

Social Media

I do not accept friend or contact requests from current of former clients on any social networking sites (Facebook, LinkedIn, etc.). Adding clients as friends or contacts can compromise confidentiality and privacy. It also blurs the boundaries of our therapeutic relationship. My professional practice also includes non-clinical aspects such as education, training, and supervision for which I use Facebook, Twitter, LinkedIn, and a website to share blog posts, practice updates, and connect with colleagues and students. There is no expectation that you, as a client, will want to follow any of this information but if you choose to do so please know that I have not recommended it and it can possibly be a risk to your confidentiality.

Please be aware that I will not be able to follow any of your social media or personal information on the Internet. If there is material from your online life you wish to share with me, please bring them into our sessions where we can view and explore them together, during the therapy hour. If you use location-based services on your mobile phone, you may wish to investigate the potential privacy issues related to using these services. Social media linked to mobile devices sometimes have a “check in” feature. You should be aware that intentionally or unintentionally “checking in” from an office location where clinical services are provided may make it possible for others to surmise that you are a therapy client which can be a risk to your confidentiality and privacy.

Communication

If you need to communicate with me between sessions, the best way is by phone, 727-688-5800. If I am unable to answer you can leave a voice message or text and I will return your call as soon as I am able. If I am away or unavailable for an extended amount of time my outgoing voicemail message will have detailed information about my ability to return messages.

Email and text messaging is a risk to your privacy and unreliable as I cannot be sure I will receive these messages in a timely manner. I prefer using email and text messaging only to arrange or modify appointments, if necessary. Please do not email or text content related to therapy sessions, as these are not completely secure or confidential.

If you choose to communicate with me by email and/or text message, be aware that these are retained in the logs of your and my Internet Service providers. While it is unlikely that someone will look at these logs, they are, in theory, available to be read by the system administrators of the ISP. I cannot guarantee confidentiality or HIPAA compliancy with emails and text messages.

You should also know that any emails and text messages I receive, and any responses technically become a part of your clinical record.

I have read, understand, and agree

CONFIDENTIALITY

Because of the laws of this state and the guidelines of the therapist's profession, these privacy rules will be followed:

All information will be held confidential and privileged unless the psychotherapist has suspicion of neglect or abuse of a child, a senior citizen or a disabled person, in which case a report will be made as required by law to the appropriate law enforcement and social welfare agencies.

All information will be held confidential and privileged unless I report suicidal or homicidal ideation, intent or plan, in which case a call to authority and/or a report will be made as required by law to the appropriate law enforcement and social welfare agencies.

Other information may be released in accordance with the Heath Insurance Portability and Accountability Act as described in this office’s Notice of Privacy Practices. I may have to release your records when ordered to do so by court subpoena. However, Julie Wells will discuss this with you beforehand and request a written release of information from me, if she judges this to be in my best interest.

Text messages are NOT confidential or HIPAA compliant. Please do not send confidential information via text.

I have read, understand, and agree

Required

LEGAL/COURT INVOLVEMENT

I understand that if I enter into treatment with Julie Wells, I am agreeing not to involve Journey Into Wellness Counseling Services in legal/court proceedings or to attempt to obtain records of treatment for legal proceedings. This prevents misuse of my treatment for legal objectives.

The goal is to support me in achieving therapy goals, not to address legal issues that require an adversarial approach.

This practice does not provide disability evaluations, forensic assessments, or court-related opinions. Therapy services are focused solely on personal growth and mental health support.

In situations requiring court involvement, the fee is $750 per hour for court appearances and $750 per hour for preparation for court testimony including, but not limited to, consulting with attorneys, reviewing the file, report/letter writing and time spent traveling to court and waiting to testify.

In addition, since an entire day of clients would need to be cleared for attendance at court, a full day of 8 hours @ $750 per hour for each day of court or deposition request will be charged. There are additional fees for parking and mileage. A retainer for court expenses will be due and payable a minimum of two weeks prior to a scheduled court appearance. In the event of a settlement or cancellation of the trial/hearing with less than 48-hour notice, a charge will be levied for those hours originally set aside for the trial/hearing. These services are not reimbursable by your medical insurance.

I have read, understand, and agree

Required

MINORS

While encouraging parental involvement, we must also provide adolescent patients with an opportunity to speak privately with a health care provider. Although the client is granted the right to inspect the chart, the minor will give written signed consent before a parent will be allowed to access the chart of a minor before, they reach age 18.

This practice confirms the minor’s independent rights to maintain confidentiality of his or her therapy and mental health treatment records. If found to be in best interest of minor’s treatment plan goals, updates on treatment goal progress may be shared, upon request, to the non-custodial or non-attending parent of children, under the age of 18.

Julie Wells cannot be an advocate for either side of custody determinations, unless required by state and federal mandatory reporting laws, and will not be able to testify as an expert witness regarding issues such as visitation, custody or fitness to parent.

I have read, understand, and agree

Required

GRIEVENCE PROCEDURE *

If at any time you are dissatisfied with your treatment, please discuss your concerns with me directly so we can work together to resolve them. If, after doing so, you would like a referral to a different therapist, I would be happy to assist you. If you ever have serious concerns that are not resolved successfully with me directly, the complaint will be referred to the respective licensing and/or Certification Boards such as the Florida Department of Health.

Telehealth refers to the delivery of healthcare services—such as assessment, diagnosis, consultation, treatment, or education—using secure electronic communications instead of in-person visits. This may include telephone calls, video conferencing, still image transmission, patient portals, or other digital tools.

Even if we are currently meeting in person, please review and sign this section so that telehealth may be used if needed in the future.

While telehealth can offer convenience and flexibility, it carries some privacy and technical risks. Electronic communication can potentially be forwarded, intercepted, or altered without your knowledge, despite reasonable security measures. Systems accessed by employers, shared networks, or unsecured internet connections may further reduce privacy. It is your responsibility to use a secure network whenever possible.

Despite best efforts, technical failures can disrupt or distort communication. Additionally, medical evaluations done via telehealth may limit your provider’s ability to fully assess certain conditions. You may opt out of telehealth at any time without impacting your ability to receive future care from this office.

Telehealth services are only available while you are physically located in the state of Florida at the time of the session. Billing and insurance processes are handled as they would be for an in-person session. It is your responsibility to confirm whether your insurance covers telehealth services.

By consenting to telehealth:

You acknowledge that highly sensitive information (such as mental health, substance use, or sexual health) may be discussed electronically.

You understand that platforms like Skype or FaceTime may not be HIPAA-compliant, and you accept the risks if choosing to use them.

You agree to take reasonable steps to protect your own privacy (e.g., secure passwords, private spaces).

You acknowledge that your provider is not responsible for confidentiality breaches caused by third parties or your own electronic use.

You accept responsibility for following your provider’s recommendations and understand that no outcome or result can be guaranteed.

You agree that records of telehealth sessions will be maintained securely and are subject to the same state and federal privacy laws as in-person care.

You release your provider from liability, to the extent allowed by law, for technical errors or data breaches beyond their control.

By electronically signing this form, you acknowledge the risks of electronic communication, accept the limitations of telehealth, and agree to participate voluntarily.

I have read, understand, and agree

POST-DEATH CONFIDENTIALITY & OPTIONAL DISCLOSURE

This section lets you choose whether I may share limited information after your death in rare, serious circumstances.

Confidentiality normally continues after your death under Florida law (§§ 90.503 and 394.4615, F.S.).

This section is optional. You may change or revoke your choice at any time before your death.

I do not authorize release of my records after my death, except if legally compelled by court order.

I authorize my therapist, at her professional discretion, to release limited information after my death only for serious matters such as homicide, suspicious death, kidnapping/missing person investigations, preventing ongoing harm or abuse, or clarifying estate/custody matters I have directly discussed.

I prefer not to decide at this time. I understand I may choose later.

Clear selection

POSSESSION OF A WEAPON OR FIREARM *

I understand that no weapons are allowed inside the counseling office. Any weapon, whether permitted for concealed carry or not, must be left in the vehicle or at home. Failure to do so will forfeit the session and future sessions will have to be reevaluated.

Required

CONSENT TO TREAT: By signing below, I am consenting to engaging in a therapeutic relationship with Julie Wells LCSW9966, Licensed Clinical Social Worker. I have read and have been offered a copy of these policies and agree to full responsibility for all expenses incurred during my treatment with Julie Wells LCSW9966. I understand that I have a right to withdraw from treatment at any time. The nature of treatment, my rights as a client, and the limitations in confidentiality has been explained to me.

I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature.

Please electronically sign your name below:

Full Legal Name *

Date

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