Pay-It-Forward Rate (Optional: please contact me if you wish to be charged this rate. This rate helps provide access to services to disenfranchised and marginalized individuals that otherwise have trouble accessing care) - $222 per 60 minute appointment
Couples therapy - Initial assessments (60 minutes) = $177
Couples therapy - (60 minutes) = $177
As of January 1, 2022, 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. You are entitled to request this Good Faith estimate at any time.
Location and Jurisdiction
Florida: By initiating this counseling relationship, you affirm that you are currently located in Florida during the time you receive therapy or located outside of the U.S. Your provider is licensed to practice psychotherapy as a clinical social worker in Florida for the purpose of diagnosing and treating mental health concerns, and is governed by the jurisdiction in Florida.
Louisiana: By initiating this counseling relationship, you affirm that you are currently located in Louisiana during the time you receive therapy or located outside of the U.S. Your provider is licensed to practice psychotherapy as a clinical social worker in Louisiana for the purpose of diagnosing and treating mental health concerns, and is governed by the jurisdiction in Louisiana.
Social Media and Professional Boundaries
Heather may have professional social media accounts. Heather is bound by HIPAA to protect your privacy to her best ability, therefore Heather does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). Adding clients as friends or contacts on these sites can compromise confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Heather may keep a Facebook Page for her professional practice to allow people to share her blog posts and practice updates with other Facebook users. While you are welcome to view this Facebook Page and read or share articles posted there, Heather will not accept clients as "fans" to help protect confidentiality, and to help avoid the risk of appearing to be asking for testimonials, which is against professional ethics. If you are especially pleased with your experience, you are welcome to tell others outside the context of Heather's business pages on social media. Heather is enacting best practices by requesting that you refrain from attempting to interact with her professional social media accounts as a client, and Heather may not respond to any social media interaction if it may pose a risk to your confidentiality.
Termination
When you are ready to stop services, please let your psychotherapist know as this is an important part of the therapy process. It is important to not simply stop responding to messages or stop scheduling sessions. You may ask your therapist for additional information about the reasons for this. Your therapist can help you find local resources if I wish to continue treatment in person, summarize the work we have accomplished, and help you experience a positive goodbye. You can take a break from therapy and return later if desired. Your therapist will help explain how that will work.
Litigation, Mediation and Arbitration
If there is a dispute, you agree to attempt to resolve any disputes with Heather directly. If a resolution cannot be found, then you agree to attempt mediation first, then arbitration, saving litigation for the last option if no other methods of dispute resolution are satisfactory.
Professional Will
In this profession, it is best practices to have a process in place for care coordination in the event the provider is incapacitated by sudden severe illness, injury or death. Should this occur, you will need to be aware that there is one professional psychotherapist, also located in Florida, who will have access to records only for the purposes of contacting current clients and informing them their provider is no longer available, either temporarily or permanently, and assisting each client with a transfer of their care. This professional is also bound by HIPAA and professional ethics to honor confidentiality. My executor for my professional will is Melissa Garner. She is a Licensed Mental Health Counselor in the state of Florida. I hope that she will never need to contact you, but I will need your permission for her to have "in case of emergency" access to your contact information to proceed with treatment.
Appointment Reminders/Self-Scheduling - Opt-In
Appointment reminders are not always HIPAA-compliant as they involve sharing protected health information throughout electronic data exchange processes, and therefore are not offered with this practice. However, many clients would prefer to have appointment reminders sent to them for convenience, despite knowing that this is not a HIPAA-compliant exchange of information. Please indicate whether you wish to opt in to appointment reminders using voice, text, or both. You can include this information on the Intake form. As another convenience feature, you may have the ability to self-schedule appointments directly through the provider's website. You can opt out of self-scheduling by not using this feature. While every effort is made to protect personal health information including your name, technology prevents 100% protection. By using self-scheduling, you understand this involves some amount of risk that your name may be transmitted outside of fully HIPAA-encrypted technology spaces.
Electronic Payment and Invoicing - Opt-In
Electronic invoicing and payment allows you to pay with convenience using any credit card. You enter the data yourself and the website is secure, but may not meet full standards for HIPAA-compliance. If you do not wish to use the electronic invoicing and payment processing, please discuss HIPAA-compliant options with Heather. At any time, you can revoke your participation in the electronic invoicing and payment process, but you will need to do so before scheduling your next session in order to have time to process invoicing and payment via alternate means.
Electronic Communication - Opt-In
Some forms of communication are not 100% secure. If you text Heather from an unsecured phone number, you may be sharing protected health information in a non-HIPAA compliant way. You are welcome to use this method of communication for convenience, but please bear in mind that the best way to communicate for protecting your privacy is encrypted email to your therapist at
heather.moller@protonmail.com, and even using this method, privacy cannot be guaranteed once information is sent out of Heather’s data management platform unless you are using encrypted email also. If you initiate communication with Heather using SMS, it will be assumed that you are opting in to receive communication this way. Please do not share any protected health information via SMS unless you are opting in to this form of communication. You are welcome to communicate with Heather using Signal, a HIPAA-compliant messaging app that works with your existing phone number.
Electronic Signatures
Each party agrees that the electronic signatures, whether digital or encrypted, of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as manual signatures. Delivery of a copy of this Agreement or any other document contemplated hereby bearing an original or electronic signature by facsimile transmission (whether directly from one facsimile device to another by means of a dial-up connection or whether mediated by the worldwide web), by electronic mail in “portable document format” (“.pdf”) form, or by any other electronic means intended to preserve the original graphic and pictorial appearance of a document, will have the same effect as physical delivery of the paper document bearing an original or electronic signature. I further agree that selecting the box below will serve as my legally binding signature.
