Welcome to the Lipscomb Family Therapy Center (“LFTC”). This Client Services Agreement & Consent to Treatment (this “Consent Form”) contains important information about the LFTC’s services and business policies. It also contains information about privacy protections and client rights with regard to the use and disclosure of your personally identifiable information (“PII”) used for the purpose of treatment and payment. Although this Consent Form is long and sometimes complex, it is very important that you read it carefully before beginning your first session. Your therapist can discuss any questions you have about the procedures explained in this Consent Form. When you sign this Consent Form as specified below, it will represent an agreement between us and allow the LFTC to begin providing services to you.

In an attempt to expedite the verification process, Lipscomb University and the LFTC ask that you, the client, read and sign this Consent Form electronically before receiving therapy at the LFTC.

The electronic consent process requires all documents to be sent through your personal email account specified in this consent form.

By selecting the "I accept" button below and inserting your name, initials, email and date at the bottom of this Consent Form, you acknowledge and agree that you are signing this Consent Form electronically and agreeing to its terms and conditions. You acknowledge and agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this Consent Form. By selecting "I accept" using any device, means or action, you consent to the legally binding terms and conditions of this Consent Form. You further acknowledge and agree that inserting your name, initials, email address and date at the bottom of this Consent Form (hereafter referred to as your "E-Signature") is as valid and legally enforceable as if you manually signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Lipscomb University and Lipscomb Family Therapy Center. You acknowledge and agree that you are the client authorized to enter into this Consent Form.

By selecting the “I accept” button below, you specifically agree to receive, obtain, and/or submit any and all LFTC documents and information electronically. These documents and information will be collectively known as Electronic Medical Records (“EMR”), and may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that LFTC receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. You acknowledge and agree that you are able to use your personal email account specified below and are able to retain electronic communications by printing and/or downloading and saving this Consent Form and any other agreements, electronic communications, documents, or records that are signed using your E-Signature. You accept such electronic communications provided via email as reasonable and proper notice for the purpose of fulfilling any and all rules and regulations, and agree that such electronic communications fully satisfy any requirement that communications be provided to you in writing or in a form that you may keep. We recommend that you print a copy of this Consent Form for future reference. You acknowledge and agree that you will keep or maintain all electronic communications records, including this Consent Form, and print or make an electronic copy of all such records.

You have the right to withdraw and revoke your consent to submit communications via your personal email at any time. By selecting “I accept” below, you acknowledge and agree that you are aware that any such revocation may delay the process of reviewing your medical record. If you wish to withdraw and revoke your consent, you must contact the LFTC director, office manager, therapists, or other staff.

You are responsible for installation, maintenance, and operation of your computer, browser and software. Lipscomb University and LFTC are not responsible for errors or failures due to any malfunction of your computer, browser or software. Lipscomb University and LFTC are also not responsible for computer viruses or related problems associated with use of an online system. Your E-Signature indicates that you have access to the Internet, an email account capable of receiving communication from Lipscomb University and LFTC and appropriate software to review any and all electronic communications (e.g., a .pdf reader).

You may not sign/e-sign a Lipscomb University and LFTC document or transaction, including this Consent Form, on behalf of another individual, unless you have been granted specific, written and legal authority to do so by that individual or by a court of competent jurisdiction.

You agree to report any suspected fraudulent activities related to electronic signatures immediately to the LFTC director, office manager, therapist, or other staff.

You acknowledge and agree that if you falsify an electronic signature, you may be subject to appropriate civil or criminal penalties or proceedings under applicable federal and state laws.

Because of the nature of federal, state, and institutional guidelines affecting mental health and relationship care services, the information contained in this Consent Form is subject to change. You agree to indemnify, hold harmless and release LFTC, Lipscomb University and its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any changes made to this Consent Form.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You have the right to: get a copy of your paper medical record, correct your paper medical record, request confidential communication, ask us to limit the information we share, get a list of those with whom we’ve shared your information, get a copy of this privacy notice, choose someone to act for you, and file a complaint if you believe your privacy rights have been violated.
You have some choices in the way that we use and share information as we: tell family and friends about your condition; provide disaster relief; include you in a hospital directory; provide mental health care; market our services and sell your information; and raise funds.

We may use and share your information as we: treat you; run our organization; bill for your services; help with public health and safety issues; do research; comply with the law; respond to organ and tissue donation requests; work with a medical examiner or funeral director; address workers’ compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

YOUR RIGHTS

You can ask to see or get a paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

Since you pay for a service or health care item out-of-pocket in full, we do not share that information for the purpose of payment or our operations with your health insurer.

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

You can complain if you feel we have violated your rights by contacting us using the information above. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to

200 Independence Avenue, S.W., Washington, D.C. 20201,
calling 1-877-696-6775,
or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described in the following, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: share information with your family, close friends, or others involved in your care; share information in a disaster relief situation; include your information in a hospital directory.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: marketing purposes, sale of your information, and most sharing of psychotherapy notes. In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways. We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. We can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat to anyone’s health or safety. We can use or share your information for health research. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. We can share health information about you with organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. We can use or share health information about you: for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

We are required by law to maintain the privacy and security of your personally identifiable health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective Date of this Notice: March 25, 2020
LFTC Clinic Director:
Justin G. Briggs, Ph.D.
Director of the Lipscomb Family Therapy Center
jgbriggs@lipscomb.edu, 615-966-5301

Note: We will never market or sell personal information. We will never share any substance abuse treatment records without your written permission.

The therapists, supervisors, and staff at LFTC are committed to offering affordable, high quality therapeutic services to the community. LFTC is dedicated to the treatment of individuals, couples, and families and to the training of skilled marriage and family therapists. Because we are a training facility in addition to a therapy service, we are able to offer lower cost services. As a teaching center for students enrolled in the Master’s of Marriage and Family Therapy program at Lipscomb University, interns are learning the skills necessary to provide therapeutic services. Clinical supervision provided by the faculty assures that quality attention is given to the needs of those seeking therapy at LFTC. A clinical team (i.e., supervisor/s and other therapists-in-training) under faculty direction may observe therapist interns and clients. Additionally, supervisory techniques such as video recording, audio recording, in-session live supervision, and psychometric assessment instruments may be used for training, service, and, with your permission, educational and research purposes to ensure quality case management and to monitor and study client progress. All sessions may be video recorded and reviewed with faculty, supervisors, and therapist interns to ensure that you are receiving the best possible care. Video recordings are stored securely to protect client confidentiality according to state and federal laws and regulations. Most videos are erased immediately after they are viewed and all video recordings are erased at the end of your treatment. Video recordings are not made for purposes of treatment, diagnosis or prognosis, and are therefore not part of your clinical record. Copies will not be made and will not be provided to you, or others, unless required by law. By electronically signing this Consent Form, you agree to permit the therapist to video record your sessions and to use the recordings as part of the clinical supervision process.

Experiences of therapy vary depending on the personalities of the therapist and client(s) and the particular problems being addressed. There are many different methods that may be used to deal with the problems that you hope to focus on. Visiting a therapist is not like a visit to a medical doctor. Rather, it calls for a very active effort on the part of the client(s). In order for therapy to be most successful, you will have to work on things at home that are talked about during your sessions.

Therapy has both risks and benefits. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, helplessness, and other difficult emotions. We believe that therapy has stronger benefits than risks. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees, however, regarding your experiences in therapy or the outcome of your therapy.

Your first few sessions will involve an evaluation of your needs and could include your completion of several assessment instruments. By the end of the evaluation, your therapist will offer you some first impressions and present you with a general treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your opinions of whether you feel comfortable working with your therapist. Therapy involves a large commitment of time, money, and energy, so you should be careful about the therapist with whom you select to work. If you have questions about procedures at LFTC, you should discuss them with your therapist whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.

Your decision to enter therapy at LFTC is voluntary. You can stop therapy at any time and discontinuing treatment will not result in any penalty or loss of other non-therapeutic services you may be receiving at Lipscomb University.

All of the therapist interns at LFTC practice an evidence-based approach to therapy. This means their treatment plans for you are significantly influenced by scientific theory and research. Your therapist intern will ask you to contribute to this process by inviting you to complete brief questionnaires that let us know how you feel about your life in general, your relationships with others, and your experience in therapy. We use this information to track your progress and to inform our decisions as we try to help you reach your goals. We look forward to finding out what therapy can help you accomplish.

LFTC offers confidential counseling in so far as allowed or required by applicable federal and state law. This means that your therapist has a responsibility to protect information received from you during treatment. In order for any information about you to be shared, usually you must first sign a Release of Information that allows your therapist to communicate only with the person or organization identified on the release and only regarding specific information identified by you. Because this is a teaching center, all therapist interns (i.e., current graduate students) are under supervision by a licensed mental health professional. Information about your case will be shared with your therapist’s supervisor and other therapist interns in your therapist’s supervision group so that you can be provided with the best care possible. Supervisors and supervision group members are also legally bound to keep your information confidential.

Under certain conditions, the laws of the State of Tennessee allow exceptions to client confidentiality. In general, these exceptions occur under the following circumstances:

1. Your therapist is required to report suspected child abuse or neglect and to report suspected abuse of the disabled or elderly. This information is required to be shared with the Department of Children’s Services, County Sheriff, chief law enforcement official where the suspected victim resides, or a judge having jurisdiction.

2. Your therapist may give information to law enforcement or medical personnel in order to protect clients and others when there is a probability of imminent physical danger, including the potential for suicide, homicide, or serious injury on the part of the client. Your therapist may also disclose information to law enforcement or medical personnel in order to protect you from immediate mental or emotional injury. Your therapist may be required to disclose information to the courts regarding treatment information in proceedings affecting the parent-child relationship.

3. Confidentiality is not protected in connection with criminal proceedings, except communication by a person voluntarily involved in a substance abuse treatment program.

4. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by client-therapist confidentiality. Your therapist cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

When therapy occurs in a relational context (i.e., when there is more than one client in the session), you acknowledge and agree that additional limits will apply to your confidentiality. For example, your confidentiality may be violated if one of the other clients in the session shares something you said in session with someone else.

Normally, LFTC clinicians will keep separate case files for each client taking part in relational therapy. Keeping separate case files for each client allows the supervisors and therapists to create unique client records that we keep confidential in so far as allowed or required under applicable federal and state laws; however, if you take part in relational therapy, you acknowledge and agree that it is impossible for us to keep all of your information out of the other client case file/s. This means that your PII, including, but not limited to, your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, may also be recorded in the case files of those you are working with in therapy (e.g., your relationship partner, family members). For example, when a therapist provides couple therapy, both clients’ names, a description of what they discussed in session, and the therapist’s assessment of their relationship and reactions to treatment will appear in both client case files.

Most clients receive clinical services on-location at the LFTC; however, there are times when therapists provide therapy services at off-site locations either in-person or through telehealth (e.g., video conferencing, phone sessions). When this occurs, there are additional limits on confidentiality. Sessions held off-site or via telehealth may be more likely to be overheard by others due to building design limitations and lack of soundproofing measures such as insulation and white noise machines. Additionally, paper case file materials such as signed informed consent and notice of privacy practices documents may be carried on the person of the therapist, making them more vulnerable to being stolen or lost than materials that are signed and stored directly at LFTC.

Please let us know if you have any questions about limits on confidentiality in relational therapy and off-site locations and we will do our best to answer them.

This section contains important information about the use of Google Meet services to assist in the in-session interaction between you, the client, and me, the therapist or therapist intern at Lipscomb Family Therapy Center.

TELEHEALTH & GOOGLE MEET

Telehealth services allow for remote treatment and are ideal for clients who are in Tennessee but unable to meet with their therapist on location in our Nashville office. Our telehealth services allow us to provide innovative, high quality care for our clients whenever in-person therapy isn’t a good fit.

Another benefit of telehealth services is that they allow us to serve all Tennessee residents, not just those who live in an around Nashville.

Meet, a video meeting experience from Meet, allows for Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant use between health professionals and their clients. This is important because the things we will talk about while using Meet are likely to be personal and taking appropriate steps to help keep our conversations confidential is required by law and is considered best practice in the mental health field. All video and audio streams in Meet are encrypted and Meet users can join securely even when they're out of my office. This means that you and I will be able to communicate with the added confidence that the content of our discussion is secured according to industry standards.

In order to use Meet, you will have to download the Meet application from the Apple App Store or Google Play.

LIMITS ON CONFIDENTIALITY WHEN USING GOOGLE MEET

Even though Meet is an encrypted service and Google has sought and received security certifications such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits, we do ask you to please remember that there is always a risk of a breach of confidentiality whenever you share your personal information. We also want you to be aware that your computer and other electronic devices may not be secured according to health industry standards.

INFORMATION SECURITY

In order to decrease the chances that the confidentiality of your personal information is compromised, I highly suggest you consider doing the following:

1. Only use Meet when you have taken steps to decrease the likelihood that you can be overheard. These steps include:

Making sure you are alone in a room when using Meet.

Placing a sound dampening device such as a white noise machine outside the room where you are using Meet.

2. Enable two-step verification when logging into your email accounts. This security measure makes it harder for someone to breach your email and gain access to your computer or other electronic devices.

3. Limit access by being careful who you allow to use, look after, or borrow your computer or other electronic devices.

4. Be sure to log out of Meet after use.

5. Encrypt your computer and other electronic devices

To encrypt Apple-made mobile devices, you need to enable password protection on your iOS device. This can be done via the Touch ID & Passcode section of Settings. iOS mobile devices used to access clients’ PII should not be backed up to cloud storage services.

On Android devices, encryption can be enabled in the Security or Lock Screen area under settings.

To encrypt a Mac computer, enable Apple's FileVault encryption in the Security & Privacy system preferences. If there are multiple user accounts on the Mac, be sure to enable encryption on each one that requires protection. I suggest using a different FileVault password than the one associated with an iTunes or iCloud account; if an unauthorized individual gains access to an iTunes or iCloud password, it cannot be used to decrypt the computer.

Apple Time Machine backups and any external drives also need to be encrypted. When setting up a backup drive, the Time Machine can by encrypted in the Time Machine system preference by clicking Select Disk, selecting the backup drive, enabling the Encrypt Backup option, and clicking Use Disk. In OS X El Capitan, external drives can be encrypted, including a Time Machine backup drive, by right-clicking or Control-clicking it in the Finder and choosing Encrypt from the contextual menu that appears. In older OS X versions, Disk Utility can be used to encrypt a drive: select the drive in its Sidebar, then choose File > Encrypt or File > Lock, depending on the OS X version.

On a PC, enabling encryption is accomplished by activating Microsoft's BitLocker. The PC will likely need to have a Trusted Protection Module (TPM) on its motherboard, but it's often missing on cheaper PCs and even expensive older PCs. The computer must also be running the Pro, Ultimate, or Enterprise editions of Windows Vista or later. If the PC is BitLocker- compatible, the BitLocker Drive Encryption settings (called Manage BitLocker in Windows 10) can be found in the Security control panel. In some cases, external drives can also be encrypted here.

If a PC doesn't support BitLocker, a third-party encryption tool like VeraCrypt must be used.

6. Regularly implement software patches and update antivirus software on personal computers.

7. Avoid the following to reduce the likelihood of malware getting installed on your computer and other electronic devices:

Downloading bundled free software programs. Programs advertised as “free” often come with the cost of downloading malicious software to a computer.

Using file sharing, BitTorrent, and other peer-to-peer sharing services

Connecting removable media (e.g., USB chargers, thumb-drives, etc.) of unknown origin to computers. These devices can contain malware if they were previously connected to an infected computer.

Downloading scareware. Scareware is also known as rogueware and it is usually presented as Internet security software. These programs are advertised in pop-up windows that say things like “Your computer is infected!”

Clicking on unknown links in emails and on websites. These links often masquerade as advertisements and phishing emails that play on the reader’s emotions. These links may say something like “You won’t believe what happened in this video” or “These people need your help!”

8. Use a secured internet connection when conducting sessions via Google Meet. Publicly available internet connections like those available in coffee shops and airports are often not secured, meaning that others can access and monitor your internet activity, including your telehealth session.

AUTHORIZATION FOR USE OF GOOGLE MEET SERVICES

I, the client, have fully read and agree to the terms outlined in this section, GOOGLE MEET STATEMENT OF UNDERSTANDING and my signature on this consent form signifies that I give consent for use of Google Meet. I have discussed any questions I had with my therapist or therapist intern and/or Lipscomb Family Therapy Center staff and I understand the information in this consent. I acknowledge and agree that Lipscomb University and the Lipscomb Family Therapy Center cannot guarantee the privacy and confidentiality of any communication through Google Meet, and hereby hold harmless and release Lipscomb University and all its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any breach of privacy or confidentiality in connection therewith. I hereby give my informed consent for the use of Google Meet Services for myself and on behalf of any of my minor children who receive therapy services as discussed above.

When treating a minor client (a person under the age of 18), your therapist may advise a parent, managing conservator, or guardian of a minor with or without the minor’s consent, of the treatment needed by or given to a minor. If the treatment, however, is for suicide prevention; chemical addiction or dependency; or sexual, physical, or emotional abuse, the law provides that parents may not access their child’s records. For adolescents between ages 16 and 18, because privacy in therapy is often crucial to successful progress, this can lead to potential problems in therapy. Older children have special rights with regard to mental health services in Tennessee. Youths 16 years and older may provide their own consents for mental health treatment. When these youths give consent, additional consent from the parent, legal guardian or legal custodian is not needed.

LFTC therapist interns will work diligently to maintain a balance between a teenager’s need for privacy/confidentiality and a parent’s desire to access their child’s records. All therapists will work prudently with their clients to find a balance that is good for the teenager, unless they feel that the teenager is in danger or is a danger to someone else, in which case therapist interns will notify the parents of their concern.

You can expect the initial assessment and evaluation period to last from 1 to 3 sessions. During this time, you and your therapist can decide if s/he is the right person to provide the services you need in order to meet your treatment goals. Sessions are normally around 53-55 minutes in length and typically occur weekly or every other week. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation (or unless both you and your therapist agree that you were unable to attend due to circumstances beyond your control). In the event of snowy or icy weather, LFTC will follow the opening/closing schedule of Lipscomb University, which will be communicated through local media outlets. If LFTC closes for inclement weather or any other reason, reasonable attempts will be made to contact you if you are scheduled for an appointment. If you are working with a therapist using a telehealth service, you may still be able to have a session even if LFTC is closed to in-person therapy due to weather-related circumstances; please check with your therapist if you are uncertain whether or not you are scheduled for a session.

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

THERAPY COSTS

Our standard fee for an hour of clinical services is $50. If you choose to use our sliding scale schedule of fees, your fee is determined based on your family’s gross household income (i.e., $10 per 50-55 minute session for every $10K in documented annual income for each client). For example, a client who makes $10K or less per year will pay $10 per 50-55 minute session; two clients coming in for couple therapy with a combined income of $40K per year will pay $40 per 50-55 minute session. You should have been informed about your fee when you initially made your appointment. If you are unsure what your fee is, your therapist intern or front desk staff will be able to tell you. The fee given to you is for each 50-55 minute time period that you are scheduled to spend in therapy. Payment is requested at the time services are rendered and may be made with cash, check, or credit card.

If clients would like to request a fee that is different than our standard fee or sliding fee scale, they can submit a written request to their clinician or the front desk staff stating their requested fee ($10 per 50-55 minute session minimum) and describing their reason for their request. Common reasons for a sliding fee scale adjustment include documented financial hardship such as medical bills or wage garnishment.

We want our clients to have a good idea what therapy will likely cost. LFTC interns or staff normally determine a per-session fee with clients during an intake phone call prior to the first session; if clients are ever uncertain about what their session fee is, we are happy to remind them. Having an understanding of their per-session fee and average treatment duration allows clients to get a good faith estimate of treatment costs (fee x number of sessions = cost). Based on our data, estimated average total cost ranges are the following:

6 or fewer sessions cost $60-$300 (approx. 46% of clients)

7-10 sessions cost $70-$500 (approx. 14% of clients)

11-15 sessions cost $110-$750 (approx. 15% of clients)

16-20 sessions cost $160-$1000 (approx. 7% of clients)

≥ 21 sessions cost a minimum of $210 (approx. 17% of clients)

(These estimates are based on a per-session fee range of $10-$50)

OTHER LESS COMMON COSTS

Clients sometimes request other services and there are charges for these services. The fee for report writing (psychological evaluations, treatment summaries, etc.) is $25 per hour with a minimum of one hour paid in advance. The fee must be paid in full before the requested document is released. Clients and/or attorneys must pay $50 per hour for courtroom testimony by a therapist, with a minimum of three hours payable in advance, when honoring a subpoena and/or when providing testimony in court, regardless of whether or not the therapist actually testifies. If you or someone representing you requests your clinical record, there is a $10 file location fee (if the request occurs after you have terminated therapy at LFTC) and a 10 cents per page copying fee.

OBTAINING A GOOD FAITH ESTIMATE

Clients may ask their clinician for a Good Faith Estimate at any time. This Good Faith Estimate shows the costs of items and services that are reasonably expected for client health care needs for an item or service. The Good Faith Estimate document includes, but is not limited to, the following information:

Client name (included below)

Client date of birth (included below)

Description of the services that will be provided, in understandable language: At the LFTC, these services are individual, couple, or family therapy. The CPT codes most often associated with these services are:

90832: Psychotherapy 30 minutes with patient
90834: Psychotherapy 45 minutes with patient
90837: Psychotherapy 60 minutes with patient
90846: Family psychotherapy 50 minutes without the patient present
90847: Family psychotherapy 50 minutes conjoint psychotherapy with the patient present
90849: Multiple-family group psychotherapy
90853: Group psychotherapy (other than of a multiple-family group)

Itemized list of goods or services reasonably expected to be provided in connection with the scheduled services: At LFTC, this would be the expected number of individual, couple, and family therapy sessions based on a description of the average client experience (i.e., number of sessions, fee range).

Diagnostic codes, service codes, and expected charges associated with each of those goods or services. Before the first session or prior to the completion of a biopsychosocial assessment (i.e., usually within the first three sessions), it is impossible to provide clients with a specific disorder/dysfunction diagnosis (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, etc.) on their documented good faith estimate. “Other Counseling or Consultation (V65.40)” is the diagnosis we use when clients do not meet the criteria for another diagnosis in the DSM, when clients have yet to complete their biopsychosocial assessment with their clinician, or when the primary topics discussed in treatment are not related to a specific disorder/dysfunction diagnosis met by a client.

Provider name, NPI, and tax ID number (included above).

Office location where services will be provided. This may include in-person or telehealth sessions. (included above)

DISCLAIMER

The Good Faith Estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from the provider and does not include any unknown or unexpected costs that may arise during treatment. Clients could be charged more if complications or special circumstances occur. If this happens, federal law allows clients to dispute (appeal) the bill.

RIGHT TO DISPUTE

If clients are billed for more than their Good Faith Estimate, they have the right to dispute the bill. Clients may contact the clinician or facility listed on this document to let them know the billed charges are higher than the Good Faith Estimate. Clients can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. Clients may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

If clients choose to use the dispute resolution process, they must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee (at last check) to use the dispute process. If the agency reviewing a client dispute agrees with the client, the client will have to pay the price on this Good Faith Estimate. If the agency disagrees with the client and agrees with the health care provider or facility, the client will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call (800) 368-1019.

For questions or more information about client rights to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.

You will be expected to pay for each session at the time it is held. You will not be seen by your therapist when your account is in arrears (i.e., after three sessions without payment) until you pay the balance on your account unless some prior arrangement has been made between you and your therapist. As stated previously, you will be required to pay the fee for scheduled sessions you do not attend for which you do not provide cancellation notice at least 24 hours prior to the session.

LFTC does have preexisting partnerships with several organizations to provide services to their employees and/or clients. If you are associated with one of these organizations, please let your therapist know so that appropriate arrangements can be made. If you are associated with an organization that has agreed to pay for your therapy at LFTC, you will be asked to sign a Release of Information that will allow us to bill the organization for your time in therapy. Only the number of sessions you have attended and the amount billed for those sessions will be shared with the organization. If you do not wish to sign this release, we will not be able to bill the organization, and you will be responsible for payment.

Due to therapists’ busy schedules, they are often not immediately available by telephone. When your therapist is unavailable, a phone message will be left for him/her to contact you as soon as possible. Your therapist will make every effort to return your call within 1-2 business days (this time frame may be longer around holidays, university breaks, or other exigent circumstances). If you are difficult to reach, please inform the receptionist of some times when you will be available. If it is an emergency, or if you are unable to reach your therapist and feel that you can’t wait for him/her to return your call, contact your family physician or the nearest emergency room (i.e., call 9-1-1) or call the Tennessee Office of Crisis Services and Suicide Prevention at 1-800-274-7471.

At LFTC, therapist and supervisor email accounts are secured by Google according to industry standards. Google has sought and received security certifications such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits. You acknowledge and agree that there is always a risk of a breach of confidentiality whenever you share your personal information online or through email. Further, you acknowledge and agree that your email account may not be secured according to health industry standards. Therefore, please use discretion and reveal only the minimum necessary personal information when communicating via email. Email sent to therapists and supervisors at LFTC are saved and may be included in your clinical record.

We keep your PII in two sets of professional records. The first is a paper case file containing various components of your clinical record including this electronically signed Consent Form. The second set of records that contains your PII consists of your EMR. Your case file and EMR make up your clinical record (clinically relevant emails sent to therapists and supervisors may also be included in your clinical record). Your clinical record contains PII that may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. This clinical record is kept for seven years post treatment for adult clients and for ten years past the 18th birthday of minor clients. Except in unusual circumstances that involve danger to yourself or others, you may examine and/or receive a copy of your clinical record if you request it in writing. Therapist interns and supervisors at LFTC charge a $10 fee for locating and copying your clinical file. If we refuse your request to obtain a copy of your clinical record, you have a right of review it, which we will discuss upon your request. In addition to your EMR, we maintain an electronic directory of your contact information and other information including your name, address, email address, ID number, the date we opened your case file, the date we closed your case file (if applicable), and whether you are currently attending therapy sessions with a therapist at LFTC. We also keep an electronic spreadsheet that records the number of therapy sessions you have received and other information including your ID number, dates of service, fees charged, fees you paid, cancellations, and missed sessions.

All PII that we store electronically is secured by Google Apps. Unlike free Google accounts that many people are familiar with, Lipscomb University has established a contractual relationship with Google that includes a business associate agreement. Our Google Apps account comes with security measures and services not available in the more common, free Google accounts. A list of security and privacy controls available with Google Apps can be found on their security and privacy website. The Google Apps core services are audited using industry standards such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits, which are the most widely recognized, internationally accepted independent security compliance audits. To make it easier for everyone to verify Google security, they have published their ISO 27001 certificate and new SOC3 audit report on their Google Enterprise security page.

In addition to the clinical record, your therapist intern may also keep a set of psychotherapy notes. These notes are for the intern’s use and are designed to assist in providing you with the best treatment possible. While the contents of the notes vary from client to client, they can include the contents of your conversations with your therapist intern and his or her analysis of those conversations. Psychotherapy notes may also contain particularly sensitive information that you may reveal to the therapist intern that is not required to be included in your clinical record. These notes are kept separate from your clinical record and are not typically released to others. You may examine and/or receive a copy of your psychotherapy notes unless it is determined that releasing them would be harmful to your physical, mental, or emotional health.

When your case files are inactive for a period of 5-weeks or more, we will close the case file. Normally, case files can be reopened at any time should you decide to return to therapy. If we are not able to reopen your case file for whatever reason (e.g., limited therapist availability), we will be happy to provide you with a referral to see another therapist.

Once closed, a client case file and other PII is kept for 7 years after a client’s final session if the client is 18 years of age or older and for 10 years after the client’s 18th birthday if the client is under 18 at the time of treatment.

It is routine for our clients and clients at similar mental health and relationship care centers to fill out assessment instruments at the request of their therapist. Assessment instruments give us information about the types of problems our clients are dealing with and help us track clients’ progress in therapy. The information you provide in an assessment instrument helps us to improve our services to the community and may also be used for marketing and research purposes. No personally identifiable information (e.g., your name, initials, birthdate, etc.) is included on any marketing materials or published research. Upon your completion of an assessment instrument such as a questionnaire, your answers will be stored securely according to state and federal standards. Therefore, by filling out an assessment instrument at Lipscomb Family Therapy Center, you will take on a minimal risk of harm or discomfort no greater than what you would experience when filling out paperwork at your medical doctor’s office. If you have any questions or would like additional information about how we use assessment results for service and research purposes, you may ask Lipscomb Family Therapy Center Clinical Director, Dr. Justin Briggs by calling 615-966-5301.

I, the client, have fully read and agree to the terms outlined in this Consent Form and give consent for therapy. I have discussed any questions I had with my therapist and/or LFTC staff and I understand the information in this consent. Furthermore, I understand that the LFTC will abide by the above mentioned policies, procedures, and techniques in providing my treatment and training its therapists. I hereby hold harmless and release LFTC and Lipscomb University and all of its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any treatment that I or my minor children receive as set forth in this Consent Form. I hereby give my informed consent for treatment at the LFTC for myself and on behalf of any of my minor children who receive therapy services as discussed above.

By inserting my name, initials, email address and date below, I hereby acknowledge and agree that I have read and understood this Consent Form, am at least 16 years old and fully competent, and have executed the same as my own free will.

(Parents giving consent for the treatment of any of their minor children will put their name and email information, not the minor child's name and email information, in the following "Client First Name," "Client Middle Initial," "Client Last Name," "Initials," and "Client Email Address" sections.)

We want to thank you for taking the time to complete this form. Please feel welcome to contact Lipscomb Family Therapy Center with any additional questions you may have. We look forward to working with you.