Teletherapy Consent Forms (For a Minor Client)
Please complete the following questionnaire. This information will be discussed more thoroughly in session and used to determine goals for counseling.
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Email *
Name of Client *
First and last name
Client Date of Birth:
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Client Street Address: 
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Client City, State, Zip: 
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Client/Guardian Email *
Client/Guardian Telephone number(s): Home: Work: *
Client/Guardian Telephone number(s): Cell:
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Parent/Guardian Names if Client is a Minor: *
If Client is a minor, does this parent/guardian have sole authority to consent to mental health treatment for this client? *
Please explain if parents are married/share custody or if there is a custody agreement.

INFORMED CONSENT FOR TELETHERAPY SERVICES

Oceanside Family Therapy & Assessments
Informed Consent for Online Counseling, Telemedicine & Telehealth Therapy/Assessments

Telemedicine is the practice of medicine using technology to deliver care at a distance. A provider in one location uses a telecommunications infrastructure to deliver care to a patient at a distant site​. ​Telehealth refers broadly to electronic and telecommunications technologies and services used to provide care and services at-a-distance. Telehealth is different from telemedicine in that it refers to a broader scope of remote health care services than telemedicine. Telemedicine refers specifically to remote clinical services, while telehealth can refer to remote non-clinical services. Telemedicine-Telehealth means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.

The purpose of this document is to inform you, the client, about many aspects of online counseling services: the process, the counseling, the potential risks and benefits of services, safeguards against those risks, and alternatives to online services. Please read this entire document and electronically sign, or sign in ink and email toNicole@OceansideFamilyTherapy.com​ or ​Nicole@usimmigrationevaluations.com

A. Process:
1) Possible misunderstandings
The client should be aware that misunderstandings are possible with telephone, text-based modalities such as email, and real-time internet chat, because non-verbal cues are relatively lacking. Even with video chat software, misunderstandings may occur due to connection problems causing image delays or less than optimal image quality. Counselors are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online counseling before, please have patience with the process and clarify information if you think your counselor has not understood you well. Also, please be patient if your counselor asks for periodic clarification.

2) Turnaround time

Using asynchronous (not in "real time") communication such as email or instant messaging entails a “lag” of response. The counselor will make every effort to respond to email requests within a 12- to 24-hour period. If the client is in a state of crisis or emergency, the counselor recommends the client contact a crisis line or an agency local to the client. Clients may also utilize 1-800-SUICIDE or 1-800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).

3) Privacy of the counselor

Although the internet provides the appearance of anonymity and privacy in
counseling, privacy is more of an issue online than in person. Oceanside Family Therapy and Assessments has a dedicated virtual private network (VPN), if you do not have access to a secure internet network please advise this office so that we may use either

PSYCHOLOGY TODAY Sessions, Doxy or VSee as the software provider for web conferencing, and chat communications between the counselor and clients. The client is responsible for securing his or her own computer hardware, internet access points, and password security.

The counselor has a right to her privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. Clients must seek the written permission of the counselor before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook or YouTube.

C. Potential benefits: ​The potential benefits of receiving mental health services online
include both the circumstances in which the counselor considers online mental health
services appropriate and the possible advantages of providing those services online. For example, the potential benefits of video chat include the convenience for clients to potentially receive counseling from anywhere once an internet signal and necessary hardware is secured. Text-based chat has many of the same advantages of convenience, feeling reduced scrutiny from the counselor, having time to compose a response, and being able to refer back to the chat log for reference. The benefits of using asynchronous email messages may include (1) being able to send and Evolve Counseling Center receive message at any time of day or night; (2) never having to leave messages or voicemails; (3) being able to take as long as one likes to compose a message, and having the opportunity to reflect upon it; (4) automatically having a record of communication to refer to later; and (5) feeling less inhibited than in person.

D. Potential risks: ​There are various risks related to electronic provision of counseling
services related to the technology used, the distance between counselor and client, and
issues related to timeliness. For example, the potential risks of email based counseling
may include (1) messages not being received and (2) confidentiality being breached
through unencrypted email, lack of password protection or leaving information on a
public access computer in a library or internet café. Messages could fail to be received if
they are sent to the wrong address (which might also breach confidentiality) or if they
just are not noticed by the counselor. Confidentiality could be breached in transit by
hackers or Internet service providers or at either end by others with access to the client’s account or computer. People accessing the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen to people around them. Position yourself to avoid others’ ability to read your screen. Using cell phones can also be risky in that signals are scrambled but rarely encrypted.

E. Safeguards: ​Our primary platform for telehealth is HIPPA Compliant with a BBA via our professional account with Psychology Today - Sessions, which does not require of the client any downloading of apps and can be accessed directly from the link on the website, which includes a confidential virtual waiting room.

In cases where the client has stated that he or she does not have access to a secure VPN, this office has also selected an account with Doxy.me or VSee for chat and video communications to allow for the highest possible security and confidentiality of the content of your sessions. In order to benefit from these safeguards, the client is required to download, register and utilize the

chat and video software from VSee.com. Alternatively, Doxy and Sessions can be used by following a personalized link and used without downloading any new software. Your personal information is encrypted and stored on a secure server in compliance with HIPAA regulations. This office does not record any virtual sessions and we ask the same of the client to ensure confidentiality.

For ease of use,​ Oceanside Family Therapy has also made available the option of using ​Skype for chat and video conferencing sessions with international clients. Using Skype for video conferencing is not a U.S. HIPAA compliant platform, and by using this software, the client understands that the risk of information being intercepted is higher than in using Sessions, VSee or Doxy. The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others, such as creating passwords to use the computer, keeping their email and chat IDs and passwords secret, and maintaining security of their wireless internet access points. The counselor and client will also choose a password in the first session to be exchanged at the beginning of all subsequent distance sessions in order to verify the identity of the client. Please discuss any additional concerns with your counselor early in your first session so as to develop strategies to limit risk.

F. Alternatives: ​Online counseling may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving mental health services online would be receiving mental health services in person. Oceanside Family Therapy & Assessments can and will assist clients who would like to explore face-to-face options in their area. Many state and local agencies will treat low-income clients on a low or no-fee basis. Please feel free to request a referral at any time you think a different counseling relationship would be more practical or beneficial for you.

G. Proxies: ​The counselor requires this consent form to be signed by the legal guardian of any client seeking services who is under the age of 18. The name and contact information of the legal guardian will be kept as part of the client’s record.

H. Confidentiality of the client: ​Maintaining client confidentiality is extremely important to the counselor and the counselor will take ordinary care and consideration to prevent

unnecessary disclosure. Information about the client will only be released with his or her express and written permission with the exceptions of the following cases:
1) If the counselor believes that someone is seriously considering and likely to attempt suicide; 2) if the counselor believes that someone intends to assault another person; 3) if the counselor believes someone is engaging or intends to engage in behavior which will expose another person to a potentially life-threatening communicable disease; 4) if a counselor suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult; 5) if a counselor believes that someone’s mental condition leaves the person gravely disabled.

I. Records: ​The counselor will maintain records of online counseling and/or consultation services. These records can include reference notes, copies of transcripts of chat and internet communication and session summaries. These records are confidential and will be maintained as

required by applicable legal and ethical standards according to the American Counseling Association, National Board of Certified Counselors, and the Florida Board of Clinical Social Workers, Marriage and Family Therapists and Mental Health Counselors. The client will be asked in advance for permission before any audio or video recording would occur on the counselor’s end.

J. Procedures: ​The counselor might not immediately receive an online communication or might experience a local backup affecting internet connectivity. If the client is in a state of crisis or emergency, the counselor recommends contacting a crisis line or an agency local to the client. Clients may utilize the following crisis hotlines: 1-800-SUICIDE or 1-800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).

K. Payments: ​All payments will be processed through PayPal on the website at ​www.OceansideFamilyTherapy.com​ with or without a Paypal account with a credit or debit card. Also accepting Venmo (QR is on the website), or HIPPA compliant options of cash or check (paid in advance in person at the office) or bank transfer to the Oceanside Family Therapy LLC Wells Fargo account. Zelle account is (904) 234-0574.

L. Disconnection of Services ​If there is ever a disruption of services on the internet that cannot be re-established within five minutes, then the client will need to call their respective counselor to discuss how to proceed with the session. Nicole Story can be reached at 904-234-0574 or Nicole@OceansideFamilyTherapy.com


Signature of Client - Client Print Name and Date

 For Minor Clients Only:

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Date of Signature: *
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Parent 1 Sign/Print Name/Date signed
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Parent 2 Sign/Print Name/Date signed 
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Financial Responsibility Agreement & Late Cancellation/No Show Policy

As the financially responsible person for the account, I understand that my initial appointment will be approx 50-60 minutes, posted and charged at a fee of $150; $100 for each 45 minute Teletherapy session thereafter and $125 for each 60 min Teletherapy session thereafter;

$135 for each 45 minute psychotherapy individual of Walk and Talk session, if applicable; 

and $75 for each Parent Update 15-30 mins (Telehealth or onsite).

 For full rates and rates for sessions over 45mins see full rate sheet or rates page on the website at https://www.oceansidefamilytherapy.com/teletherapy-virtual-sessions or for Walk and Talk  - https://www.oceansidefamilytherapy.com/walk-and-talk-therapy

I understand that I will be financially responsible for any charges. I acknowledge that I understand, and accept the terms of the services allowed for mental health treatment.

I understand that I will be charged and am required to pay for phone consults with the therapist which last over 15 minutes, fees based on the 45-minute psychotherapy allowable amount.

I understand that I shall keep all scheduled appointments, unless a personal emergency occurs, and shall give at least 24 hours notice of my intention to cancel my appointment.

I understand that if I do not cancel my appointment at least 24 hours in advance (LATE CANCELLATION), or fail to show up for my scheduled appointment (NO SHOW), the first time this occurs I will not be charged. However, if this should occur a second time, I understand that I will be charged. I understand that I will be required to pay for the therapist’s full charge for this missed session.

I understand payment must be made in advance due to the nature or onsite appointments and that payment can be made via Zelle (904) 234-0574, 

Direct Deposit to Wells Fargo Oceanside Family Therapy LLC account 

or via Paypal.me/OceansideFamilyThera 

There is also a cart on the website listing rates and offering payment via debit/credit card through PayPal (no account required) https://www.oceansidefamilytherapy.com/walk-and-talk-therapy

I understand and agree that I am ultimately financially responsible for all fees described in this agreement.

 Client Parent/Guardian Signature and Date

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Treatment Agreement/Consent to Treatment

This document is intended to clarify in writing some of the issues we may have already discussed verbally that need to be brought to your attention regarding our professional relationship. In my work I have found that it is best to specify as well as possible the form and content of our relationship by making a mutual agreement that you may receive the service you desire. It is my assurance that I am well aware and respectful of your basic rights as a consumer and that I will respond to your needs in the most highly ethical manner, according to the standards of care for my profession, mental health and marriage/family counseling. By clarifying the services I have to offer, as the person to be treated, you may best judge whether you desire or are satisfied with them. I remain personally and professionally committed to providing you with the highest quality of service.

Client Rights

As a client of Nicole Story, Ed.S, LMFT, LMHC, Oceanside Family Therapy, LLC you have certain rights which are:

  1. To participate voluntarily in treatment with your therapist and to terminate at any time without penalty.

  2. To understand that “treatment” could include individual or conjoint therapy for up to 45/50 minutes (a therapy hour) or a double therapy session for 90 to 120 minutes conducted by your licensed therapist with no absolute guarantee of your desired results by your therapist.

  3. To participate with your therapist in exploring your goals as a client and developing a Treatment Plan, which will include the benefits and risks associated with the particular approach to therapy.

  4. To have reasonable access to your therapist by telephone in case of emergency.

  5. To have information available to you regarding your therapist’s professional license and credentials as well as access to the ethical guidelines or “Standards of Practice” in Mental HealthCounseling or Marriage and Family Therapy. Your counselor is licensed under Florida Statute 491 of the Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling of the Agency for Health Care Administration in Tallahassee, Florida.

  6. To be aware that your therapist works as a LLC who shares space and support staff with a law firm at 328 2nd Ave., Jacksonville Beach, Florida 32250.

  7. To understand that, under certain conditions, your therapist may choose to seek supervision from other qualified clinicians.

Oceanside Family Therapy, LLC - 328 2nd Ave. N., Jacksonville Beach, FL 32250

  1. To understand that, in keeping with generally accepted standards of practice, your therapist may confidentially consult with other mental health professionals regarding case management. The purpose of the consultation is to assure quality care, and every effort is made to protect the identity of clients.

  2. To have all records and other information concerning to your involvement with this office held in strict confidence and all communication with your therapist privileged, which means that no information is ever to be released to a third party without your written permission. 

    Certain exceptions are: if you are in clear and imminent danger to yourself and others; in child abuse; elder abuse and neglect cases; therapist’s subpoena or court order, if you carry and infectious or communicable disease (e.g. AIDS); insurance/third party billing; or if there is a medical emergency.


    Client Responsibilities

    As a client/consumer, I have carefully read over and signed all of the policies regarding financial responsibilities, making, keeping and cancelling appointments with this therapist and this agreement.

Consent and Authorization for Treatment

I consent to and authorize the assessment and/or treatment I will receive as a client of Nicole Story, Ed.S, LMFT, LMHC, Oceanside Family Therapy. I have read the policies of this office and received a copy of them. I understand these rules and policies and agree to follow them.

Consent and Authorization for Treatment

I consent to and authorize the assessment and/or treatment I will receive as a client of Nicole Story, Ed.S, LMFT, LMHC, Oceanside Family Therapy. 

I have read the policies of this office and received a copy of them. I understand these rules and policies and agree to follow them. All electronic Signatures in this form serve as my legally binding signature.

Signature of Client and Date

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NOTICE OF PRIVACY PRACTICES (HIPPA)

As required by the Privacy Regulations Created as a Results of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE READ AND REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the terms of my Notice to Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy in my office, sending a copy to you in the mail upon request, or providing one to you at your next appointment time.

  1. FOR TREATMENT

  2. FOR PAYMENT

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.

3. FOR HEALTH CARE OPERATIONS

I may use or disclose as needed, your PHI in order to support my business activities, including but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (i.e., answering service, billing and accounting service) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI.

4. REQUIRED BY LAW

Under the law, I must make disclosure of your PHI to you upon request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of litigating or determining my compliance with the requirements of the Privacy Rule.

5. WITHOUT AUTHORIZATION

Applicable law and ethical standards permit me to disclose information about you and your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are:

Oceanside Family Therapy, LLC - 328 2nd Ave. N., Jacksonville Beach, FL 32250
- Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations

(such as mental health licensing board or health dept.) - Required by Court Order

- Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

6. VERBAL PROTECTION

I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

7. WITH AUTHORIZATION

Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI
RIGHT TO AMEND: If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although

I am not required to agree to the amendment.

RIGHT TO REQUEST RESTRICTIONS: You have the right to request restriction or limitation on the use of disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request.

RIGHT TO REQUEST CONFIDENTIAL INFORMATION: You have the right to request that I communicate with you about medical matters in a certain way or at a certain location.

RIGHT TO A COPY OF THIS NOTICE: You have the right to a copy of this notice. COMPLAINTS

If you believe that I have violated your privacy rights, you have the right to file a complaint in writing with me or with the Secretary of Health and Human Services at:

200 Independence Ave, SW Washington, DC 20201

or by calling (202) 619-0257

Notice of Privacy Practices Receipt and Acknowledgment of Notice

Patient/Client Name and Date of Birth:

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I hereby acknowledge that I have received and have been given an opportunity to read a copy of the “Notice of Privacy Practices” of Nicole Story, Ed.S, LMFT, LMHC. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Nicole Story, Ed.S, LMFT, LMHC.

Signature of Patient/Client Date:

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