Client-Therapist Service Agreement

This document contains important information about business policies and professional services at the Center for Dialectical and Cognitive Behavioral Therapies (CDCBT). It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. If you opt-in to receive SMS text messages, this document also contains terms for such SMS text messaging. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between you and CDCBT. You may discuss any questions you have with your therapist when you sign them or at any time in the future.

Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations that you should be aware of. Your therapist has corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Goals of Counseling

There can be many goals for the counseling relationship. Some of these will be long-term goals such as improving the quality of your life. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use. Whatever the goals for counseling, they will be set by the client(s) in discussion with the therapist. The therapist may make suggestions on how to reach that goal but you decide where you want to go.

Risks/Benefits of Counseling

Counseling is an intensely personal process that can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress is typically non-linear and may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to counseling. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.

Appointments

Appointments will ordinarily be 50 minutes in duration, once per week at a time agreed upon between you and your therapist, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, please provide your therapist with 24 hours’ notice. If you miss a session without canceling or cancel with less than a 24-hour notice, you will be required to pay for the session. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancelation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

Your therapist can only meet with you when you are physically present in the state that they are licensed in. The states your therapist is licensed in can be checked on our website on the provider page. Your therapist may not be able to meet with you when you are out of state.

Confidentiality

Your therapist will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality of which you need to be aware. Your therapist may consult with a supervisor or other professional counselor in order to give you the best service. In the event that your therapist consults with another therapist or other professional outside of CDCBT, no identifying information such as your name would be released. Please note that this Informed Consent Document and confidentiality agreement includes the entire CDCBT team. Therapists are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If your therapist receives a court order or subpoena, she may be required to release some information. In such a case, your therapist will consult with other professionals and limit the release to only what is necessary by law.

Group Therapy and Confidentiality

The nature of group counseling makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that your therapist cannot guarantee that other group members will maintain your confidentiality. However, your therapist will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said during group confidential. Your therapist also has the right to remove any group member from the group should they discover that a group member has violated the confidentiality rule. Most groups have both a licensed leader and co-leader. This confidentiality agreement applies to meetings with both the leader and co-leader of the group.

Technology and Confidentiality

Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Zoom, SimplePractice, Doxy, FaceTime, telephone, email, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Your therapist will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. Should a client have concerns about the safety of their email, your therapist can arrange to encrypt email communication with you.

SMS Text Messaging and Confidentiality

By providing your phone number, you consent to receive SMS text messages from CDCBT for appointment reminders, marketing messages, and general two-way communication about your treatment and counseling relationship.  SMS messages may be sent directly from your therapist’s phone or via an encrypted phone number on RingRx or iPlum.  If you require that we use only RingRx or iPlum encrypted messaging services to communicate with you via SMS text messages, then you must either so signify in the signature section below or provide written request to your therapist. We are not responsible for delays in communication resulting from use of Ring Rx or iPlum encrypted messaging services.

Message Frequency

You will get more than one message from us unless you opt-out, and while messaging frequency varies, you will likely receive one message per week. CDCBT reserves the right to alter the frequency of messages at any time to increase or decrease the total number of messages. CDCBT and carriers are not liable for delays or undelivered messages.

Message and Data Rates

Message and data rates may apply based on your mobile carrier’s terms.

Privacy Policy

Your information will be handled in accordance with our Notice of Privacy Policy – SMS Messages.

Cancellation/Opt-Out Instructions

You can opt out of receiving SMS messages at any time by replying STOP to any message we send you. After you opt out of text messaging, you will receive one additional message confirming your request has been processed.

Help/Customer Support

Text the word HELP for support. You may also contact us directly at info@sanantoniodbtcbt.com or 210-906-8428.

Liability

We are not responsible for any charges, errors, or delays in SMS delivery or undelivered messages caused by your carrier or third-party service providers.

Professional Fees and Confidentiality

You are responsible for paying at the time of your session unless prior arrangements have been made. Payments must be made by credit card, check or cash. If you refuse to pay CDCBT or dispute your debt with your credit card company, CDCBT reserves the right to use an attorney or collection agency to secure payment and to provide your credit card company with relevant documentation for verification of services, such as name, nature of service, and date of service. You will also be responsible for returned check and dispute fees.

Individual session fees are set by each therapist. If you have questions about their fee schedule, then please talk with your individual therapist. Group session rates differ depending on the group. To receive sliding scale fees, you and your therapist may discuss and agree on an appropriate fee. Fees are subject to change at therapist’s discretion.

If you are in a group or a class, you will need to buy a skills binder, available at cost from us, or purchase one on your own. If you require additional binders, these are also available at cost.

Coaching calls, 10 minutes and under, are included with the cost of individual therapy. Your therapist will work with you to ensure calls stay under this limit. If you choose to have a coaching call over 10 minutes, it will be charged as a partial session in 15 minute increments according to the individual therapist’s fee.

Occasionally, case coordination may be necessary If your case requires the participation of more than one therapist on the team. All case coordination under 10 minutes are included in the cost of therapy. Any case coordination over 10 minutes will be charged at the professional rate of each participant in the meeting in 15 minute increments. Case coordination meetings over 10 minutes will be discussed with and approved by you prior to the meeting.

If you are currently or anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. Please note that if any of your therapists (individual, couples, family, or group) are subpoenaed or otherwise required to participate in a legal proceeding as a result of providing professional services to you, you will be responsible for paying them their forensic rate for all time expended on preparation, transportation, standing-by and testimony. Please ask your specific therapist about their forensic rate because all therapists set their own rates.

If the party responsible for paying for treatment is not the person in individual therapy, we require that an active credit card be kept on file for payment. If you wish to use some other form of payment, please send it with the person who is in therapy at at the time of their appointment. If no other payment form is provided, the card on file will be charged.

Record Keeping

Your therapist will prepare records of your counseling sessions and a treatment plan that includes goals for your counseling. These records are made to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information that specifies what information is to be released and to whom. CDCBT will maintain Client records for at least 7 years following the Client’s last visit. CDCBT will store records either electronically on SimplePractice (a HIPAA compliant web platform) or a USB flash drive or in a paper file that is kept in a locked cabinet in CDCBT’s offices. After the applicable retention period has expired, CDCBT will destroy all Client records.

Supervision

LPC Associate clinicians are supervised by Lori Prado, LPC-S. If you have any concerns, please contact Lori Prado, LPC-S, 210-239-8978.

Insurance

All therapists at CDCBT are out-of-network providers. Your therapist will supply you with a receipt of payment (Superbill) for services that you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, we will do our best to assist in referring you to a provider on your insurance plan.

Contacting Your Therapist

Since your therapist may be practicing Dialectical Behavioral Therapy, coaching calls may be a part of your treatment plan. If you do not know your therapist’s phone number, call the front desk at 210-906-8428. If coaching calls are a part of your treatment plan, you and your therapist will discuss and agree upon the boundaries for their use. Your therapist may not always be immediately available by telephone. CDCBT therapists do not answer their phone when they are with clients or otherwise unavailable. At these times, you may leave a message on their confidential voicemail and your call will be returned as soon as possible or within 24 hours for non-emergent concerns. If you feel you cannot wait for a return call or it is an emergency situation, go to your nearest emergency room or call 911. Please note the fee schedule for coaching calls over 10 minutes listed in the professional fees section of this document.

Consumer Complaints

A person who provides professional counseling services to clients must be licensed, unless exempted by state law. A consumer who wishes to file a complaint against an individual licensed by the board may do so by calling 1-800-821-3205 or may visit https://www.bhec.texas.gov or may write to the Texas Behavioral Health Executive Council, George H.W. Bush State Office Building, 1801 Congress Ave., Ste7.300, Austin, Texas 78701.

 

USER CONSENT / Opt-In: Please indicate whether you agree to receive text messages from CDCBT. If yes, then I understand that message frequency varies and message and data rates may apply.  I understand that I may opt out by replying with “STOP” at any time I choose to stop getting messages and I may reply “HELP” for assistance. I understand consent is not required in order to receive therapeutic services.”

____YES           ____NO

If you answered yes above, then please indicate below whether or not you require that all SMS text messages to or from your therapist be sent via their RingRx or iPlum encrypted phone number.  You understand that CDCBT is not responsible for delays in communication resulting from use of Ring Rx or iPlum encrypted messaging services.

____ I require SMS text messages to be sent via RingRx or iPlum.

_____ I do not require encrypted SMS messages

BY SIGNING BELOW, YOU ARE AGREEING THAT YOU HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

 

_______________________________________________