Walk & Talk 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 WALK-AND-TALK SERVICES

Walk-and-talk is a form of psychotherapy or consultation while walking outdoors in public places. This clinician offers walk-and-talk sessions as an optional treatment modality. Walking sessions typically take place along Atlantic Beach, QHYCC or UNF Trails. Some clients enjoy the experience of movement while talking or feel more comfortable talking side-by-side, rather than sitting online.

Walk-and-talk sessions can be used intermittently or regularly, and may be discontinued at any time.

If you participate in walk-and-talk, you understand and agree to the following:

That there are risks associated with any general outdoor activity, that you’re willing to assume these risks, and that I’m not liable for such risks. Hazards may include stumbling on uneven surfaces, bee stings, sunburn, twisted ankle, medical issues, accidents, etc.
That you have no known health problems or medical conditions which could in any way limit your ability to safely participate, and you assume all health risks associated with this activity. That I will be acting as a mental health professional under the scope of my mental health license—not as a fitness trainer or in any other capacity.

That you certify you have adequate insurance to cover any injury or damage you may experience while participating in walk-and-talk sessions, or that you agree to bear the costs of such injury or damage.
That because walk-and-talk sessions are outdoors, there’s some risk to confidentiality, including but not limited to the possibility of encountering a person one of us knows, some of our conversation may be overheard by someone, or that someone may recognize me as a mental health professional. Though, there would be no obvious sign that it is a therapy session, it is possible that they may ask you who I am. Confidentiality cannot be as controlled as in the office (when available) or online in a BBA Teletherapy platform.

Walk and Talk Therapy is treatment oriented only and not intended for forensic or court involved cases. It is not intended to be used in divorce cases, DCF cases or custody evaluations. For court involved cases see fees for testimony retainer. Notes/charts for walk-in-talk therapy are not designed for court and you are waiving your right to request them for court or for others to request them. (For minors both parents must sign).

This informed consent form does not expire while receiving services at this practice, unless you choose to revoke it in writing. Please sign and return:


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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Date of Signature: *
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Parent 2 Sign/Print Name/Date signed 
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Date of Signature: *
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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; 

$135 for each 45 minute psychotherapy individual walk and talk session thereafter 

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 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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Date of Signature: *
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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.

Signature of Client and Date

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Date of Signature: *
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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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Date of Signature: *
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