Practice Policies

( CLIENTS WILL BE REQUESTED TO E-SIGN AND AGREE THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.)

HIPAA & Notice of Privacy Practices

Yaarah Family Therapy & Wellness Services Inc. (Yaarah Therapy & Wellness Services) is committed to maintaining and protecting the confidentiality of the individual’s PHI. Yaarah Therapy & Wellness Services is required by federal and state law, including the Health Insurance Portability and Accountability Act (“HIPAA”), to protect the individual’s PHI and other personal information. Yaarah Therapy & Wellness Services is required to provide the individual with this Notice of Privacy Practices regarding their specific policies, safeguards, and practices. When using or disclosing an individual’s PHI, Yaarah Family Therapy & Wellness Services Inc. is bound by the terms of this Notice of Privacy Practices, or the revised notice of Privacy Practices, if applicable.

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

I am required by law to maintain the privacy and security of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). I must abide by the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization (“Authorization”). It is your right to revoke such Authorization at any time by giving me written notice of your revocation.

Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent.

I can use and disclose your PHI without your Authorization for the following reasons:

1. For your treatment. I can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated by a physician or a psychiatrist, I can disclose your PHI to him or her to help coordinate your care, although my preference is for you to give me an Authorization to do so.

2. To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I have provided to you, although my preference is for you to give me an Authorization to do so.

3. For health care operations. I can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws.

Certain Uses and Disclosures Require Your Authorization.

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.

b. For my use in training or supervising other mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law, and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

Certain Uses and Disclosures Do Not Require Your Authorization.

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

YOUR RIGHTS YOUR REGARDING YOUR PHI

You have the following rights with respect to your PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made.

You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization.

I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, and my address and phone number are:

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;

2. Calling 1-877-696-6775; or,

3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

I will not retaliate against you if you file a complaint about my privacy practices.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on September 20, 2013.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.

This Notice of Privacy Practices is subject to change. If this notice is changed, you may obtain a copy of the revised notice by contacting me at office@yaarahtherapy.org

If you have any questions about my Notice of Privacy Practices, please contact office@yaarahtherapy.org

I acknowledge receipt of the Notice of Privacy Practices of Yaarah Family Therapy & Wellness Services Inc. (Yaarah Therapy & Wellness Services).

(PROSPECTIVE CLIENTS WILL BE REQUESTED TO E-SIGN AND AGREE THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.)

1. I understand that the provider wishes me to engage in a telehealth consultation.

2. I understand that I am not currently a client and a consultation is required prior to engaging in formal service agreement with the provider.

3. I understand that phone or video conferencing technology will be used and that this consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

4. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

5. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

6. I will have a direct conversation with my provider, during which I have the opportunity to ask questions in regard to the treatment, procedure, the risks, benefits, and any practical alternatives; this will be discussed with me in English.

7. I understand that the first 15 minutes of the scheduled telehealth consultation will be free of charge.

8. I understand that should I desire more time than 15 minutes or a second consultation, I should request an initial session with the provider and I will be charged a standard session fee for a check in session of up to 30 minutes for $160.

9. I understand that I am responsible for the fee associated with this additional consultation time/check in session service and it must be paid prior to the service.

10. I understand that standard practice policies apply, including late cancellation, no show, and mandated reporting laws. Cancellations, no-shows, and re-scheduled sessions will be subject to a full charge if not received at least 24 hours in advance This is necessary because a time commitment is made to you and is held exclusively for you.

11. I understand that if not waitlisted, I have up to 2 weeks to schedule an appointment with Yaarah Therapy & Wellness Services, if both client and therapist agree that this is a good fit. If you do not schedule a first therapy appointment within 2 weeks of your initial consultation, we respect your decision and will assume that you are not interested in working with Yaarah Therapy & Wellness Services at this time.

12. I understand that after my initial consutation and after I am established as a client, I will need to complete the intake process. The Intake and consent forms will provide a clear framework for our work together. Completion of intake packet is required at least 24 hours prior to first appointment. If not received by the deadline, the appointment may be cancelled and I will be responsible for associated cancellation fees.

13. CONSENT TO USE THE TELEHEALTH HIPAA- compliant Telehealth via phone or video will be the technology that we will use to conduct telehealth videoconferencing appointments. You will be provided with the link for the appointment in advance. By signing this document, I acknowledge:

The telehealth platform used is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911, 988, or other local emergency/crisis response services.

Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither the telehealth platform nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

The Telehealth platform used facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

I do not assume that my provider has access to any or all of the technical information in the Telehealth platform– or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth platform Service.

To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

I understand that I may not audio or video record or photograph my provider or any portion of the appointment with the provider.

( CLIENTS WILL BE REQUESTED TO E-SIGN AND AGREE THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.)

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy, and it Is an honor to support you on your healing journey. The outcome of your treatment depends largely on your commitment, which at times may cause discomfort, as remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. It is your therapistʼs intention to provide trauma-informed, compassionate, client- centered, culturally-affirming, and collaborative services that will assist you in attaining your goals. Based upon the information that you provide to your therapist and the specifics of your situation, your therapist will provide recommendations to you regarding your treatment and partner with you to explore and achieve what it is that you want for yourself. You have the right to agree or disagree with your therapistʼs recommendations. Your therapist will also periodically provide feedback to you regarding your progress and will invite your participation in the discussion. Due to the varying nature and severity of circumstances of each client/patient, your therapist is unable to predict the length of your therapy or to guarantee a specific outcome or result.

Intake Process

Clients are invited to access our convenient and collaborative intake and assessment process in the secure portal, which includes symptom questionnaires, consents, and intake forms that will prompt you to share some information about yourself, indicate goals, and what you envision for your healing journey. All of this will help your therapist better support your intentions for your highest good, peace, wisdom, growth, sustainability of lifestyle, and connection with self and others.

It is important that you complete the intake packet honestly and thoroughly prior to the first therapy appointment, so that your therapist can best support you. The Intake and consent forms will provide a clear framework for our work together. Completion of intake packet is required at least 48 hours prior to first appointment. If not received by the deadline, your appointment may be cancelled and you will be responsible for associated cancellation fees. Please bring up any questions that you might have regarding the intake forms or your services in your first session.

Confidentiality

The session content, communications, and all relevant materials to the clientʼs treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expertʼs report to an attorney.

Occasionally Yaarah Therapy & Wellness Services/ your provider may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, Yaarah Therapy & Wellness Services will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and Yaarah Therapy & Wellness Services does not wish to jeopardize your privacy; however, if you acknowledge your provider first, your provider will be more than happy to speak briefly with you, but it may no be appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Minors

Clients over the age of 12 years may consent for their own treatment. Communications between therapists and patients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their childʼs treatment are often involved in their treatment. Consequently, your therapist, in the exercise of his or her professional judgment, may discuss the treatment progress of a minor patient with the parent or caregiver. Clients who are minors and their parents/caregivers are urged to discuss any questions or concerns that they have on this topic with their therapist.

Relationship Therapy: Limited Secrets Policy

If you are here to work on a relationship problem/ complex dynamics, it’s important for you to understand what your therapist believes about partnerships.

First of all, I do not have preconceived notions about whether you should stay together or part ways. I believe it is important to explore such questions openly, honestly, and thoroughly. Once your goals are established, I will work diligently to support you in achieving them, whatever they may be. Second, you are entrusting me to use my professional judgment as it relates to individual confidences.

By signing this form, you are acknowledging that anything you communicate to your therapist individually by phone, email, message, or any other means may be important to bring up and work on in a relationship therapy session, and the therapist reserves the right (but not the obligation) to do so, under clinical discretion.

Appointments

All appointments are offered via telemedicine. Sessions are typically scheduled one time per week on the same day and time if possible. Your therapist may recommend a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance, collaboration, and completion of requested documents and assessments within 24 hours of scheduled appointments greatly contributes to a successful outcome.

The standard meeting time for psychotherapy is 45-50 minutes. Requests to change the 45-50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance. You may use the client portal to book, reschedule, and cancel appointments, review and submit documents, and utilize treatment materials/resources in between sessions. Please note that completion of forms is required for services.

Telehealth Consent: https://intakeq.com/c/Fdd9y6

Cancellations

No Shows, cancellations, and rescheduled sessions will incur a full charge if not notified at least 48 hours in advance.

For contract clients, this fee is $200.

This policy is in place because your reserved time is a commitment made to you, exclusively.

Late arrivals may result in a shortened session, but the full session fee applies.

Late cancellation or no-show fees will be charged to the card on file on the day of the missed service/cancellation.

As a courtesy, three (3) discounted late-cancellation fees will be available per calendar year.

Full details on the Cancellation policy are found here: https://intakeq.com/c/KiaIXQ

Payment of Fees

Paying for therapy is often a very sensitive topic, and we can discuss your concerns about payment as needed. We offer our services on a fee-for-service basis to individuals who do not have insurance, choose not to use their insurance, or have insurance that we do not accept. Any other third-party payee arrangements will be formally arranged prior to the onset of services, and/or as needed during course of treatment. Should there be changes in financial arrangement or service fees, Yaarah Therapy & Wellness and/or my provider will provide at least 2 weeks notice of the change.

Clients are required to pay the full fee for each session or service prior to or at the time the service is provided, for all services not covered by insurance. This may include not only sessions with the client, any collateral contact or communication with third parties regarding client treatment, additional administrative work, evaluations, reports, any time spent reviewing or producing documentation, products, payments/copayments, Late Cancellation or No Show fees**.**

Payment is automatically charged to the card on file on the day of your service if you have not made a pre-payment or agreed upon arrangement with your therapist. Upon scheduling your appointments, you have the opportunity to provide credit card information which will be kept on file to be used as a form of payment for fees incurred for services, late cancelations, missed appointments, returned checks, or past due account balances. A receipt/invoice/statement will be provided in the client portal for all payments made.

Upon agreement with your provider, alternative payments can also be made through the following methods:

Square

IvyPay

Zelle

Paypal

ACH

Financial Responsibility Agreement & Credit Card Authorization Form: https://intakeq.com/c/xjIN0J

Non-payment of fees

If a payment declines/fails, reattempts will be initiated for the full payment and/or a portion thereof. A $30.00 service charge will be charged for any checks returned for any reason for special handling. Once an account becomes past due and late fees are assessed, you must pay past due charges, plus late fees to bring the account current and schedule appointments. Unpaid balance may result in late fees, assessed at the rate of $50 monthly on accounts with a delinquent balance of $50 or greater.

Late fees will continue to be assessed every 30 days and are due the day after they have been assessed. No more than one late fee will be assessed in a 30 day period. If your account is past due, please be advised that Yaarah Therapy & Wellness Services may be obligated to turn past due accounts over to a collection agency or seek collection with a civil court action. By signing below, you agree that Yaarah Therapy & Wellness Services may seek payment for your unpaid balance with the assistance of a collections agency. Should this occur, Yaarah Therapy & Wellness Services will provide the collection agency or Court with your name, address, phone number, and any other directory information, including dates of service or any other information requested by the collection agency or Court deemed necessary to collect the past due account. Yaarah Therapy & Wellness Services will not disclose more information than necessary to collect the past due account. Yaarah Therapy & Wellness Services will notify you of any intention to turn your account over to a collection agency or the Court by sending such notice to your last known address and/or email. Unpaid balance may result in termination of services.

Superbills

A Superbill can be provided to you if you are paying full fee and would like to seek reimbursement from your insurance provider if you have out of network benefits. A superbill is a document for insurance carriers that provides information about the services that you received, including identifying information about you, information about your treatment provider, and the type of service provided. While a mental health diagnosis might be required by insurance providers, the superbill would not include details about what is discussed in your treatment sessions. Please note that not all insurance providers provide reimbursement for out of pocket therapy payments, so if you are seeking reimbursement, it is recommended that you contact your insurer to confirm that they provide superbill reimbursement for an out-of-network provider who is a Licensed Marriage and Family Therapist. It is also recommended that you clarify reimbursement rates for your out of pocket expenses, as some insurers may only provide partial reimbursement.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

HIPAA & Notice of Privacy Practices: https://intakeq.com/c/8eTCO8

Communication Policy: https://intakeq.com/c/DqHV7f

Electronic Communication

Yaarah Therapy & Wellness Services cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging, you may; however, it is recommended that you send a secure message in the portal, especially if the content is sensitive. While Yaarah Therapy & Wellness Services may try to return messages in a timely manner, Yaarah Therapy & Wellness Services cannot guarantee immediate response and request that you do not regard telecommunication/ messaging as therapy or an emergency resource. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what they would consider important information, that you may not recognize as significant to present verbally the therapist.

Recordings & Photographs

Under no circumstances is a client/patient allowed to audio, video record, or photograph the therapist or conversational content of a session. The therapist will never record or photograph a client without consent and appropriate clinical rationale.

Termination

Ending relationships can be difficult, so it is a good idea to plan for your termination, in collaboration with your therapist in order to achieve some closure. The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan, needs, and the progress you achieve. Your therapist will discuss/inform you of a plan for termination/transitions as you approach the completion of your treatment goals, if it is determined that the psychotherapy is not being effectively used, if you are in default on payment, do not return forms required for services, if there is a conflict of interest, or if you or your therapist determines that you are not benefiting from treatment. Either party may elect to initiate a discussion of your treatment alternatives, which may include, among other possibilities, referrals, changing your treatment plan, or ending your therapy services. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

Court-Involvement Policy

Please be advised that the therapists and staff of Yaarah Therapy & Wellness Services do not participate in person, by phone or in writing in any court related matter that the client of Yaarah Therapy & Wellness Services may be a party to or become a party to in any way. The therapists of Yaarah Therapy & Wellness Services do not write letters regarding their clientʼs treatment to any entity, including court. The therapists of Yaarah Therapy & Wellness Services at no time will offer an opinion or recommendation in any court matter, especially as it relates to custody. If a court order is served and is requesting that a therapist of Yaarah Therapy & Wellness Services be present in person, or video, and/or there is a request for records, the client's consent will be requested before turning over confidential information. When obtaining this consent, the client will be told exactly what has been requested by court and there is no guarantee that the information will be kept confidential. This includes a clientʼs mental health history; current status and inclusive records and may not be in the best interest of the client. The therapist client relationship does not render the therapist as an advocate. The therapist will withhold any opportunity to engage in a dual relationship with the client. If called to testify in a deposition or court hearing, the client may not discern between information and records provided. All information and records are available for discovery. This may not be in the best interests of the client. The therapist reserves the right to discuss the implications of releasing information and records. When working with couples or families, it is imperative that all clients understand that if they wish to access their records during or after completion of therapy, all participants must consent to the release of such records. This also includes court letters and testimony. All participants must consent to disclosure, otherwise the therapist shall invoke privilege. When working with minors in the state of California, please be advised that minors at the age of 12 must consent to their own treatment as well as the consent to release their records. As the minorʼs therapist, it is the therapistsʼ ethical duty to inform the minor of the significance of releasing records (both verbally and in writing) as it may or may not benefit them therapeutically.

Court-Involved Fees

Please be advised that should a therapist from Yaarah Therapy & Wellness Services be court-involved or court ordered to appear in court or at a deposition, the fee stipulation is as follows:

* $2,000 per day (paid before 7 days prior to court-ordered appearance), plus $300 per hour for travel to and from the court (paid before 11:59PM PST on the day of court-ordered appearance).

* $300 per hour, billed prorated in 15-minute increments, for preparation or collateral with legal system/attorney (paid before 11:59PM on the day of each preparation or collateral service.) Please be advised that should a therapist of Yaarah Therapy & Wellness Services be ordered by court to write a letter to the court, the time shall be billed at $300 per hour (paid before 11:59PM on the day of each service.) All court related activity shall be billed in full. The therapist of Yaarah Therapy & Wellness Services will NOT be ON-CALL at anytime. Should a case be trailed, or continued, the therapist will be paid in full for each day as well as an additional $1,000 per day as it hinders the therapistʼs ability to be available to provide medically-necessary treatment to their other clients.

Subpoenas & Court Orders

The therapist may or may not agree to accept a subpoena and may assert privilege on behalf of the client to protect clientsʼ Private Health Information (PHI). Please coordinate with our office scheduler to ensure that the therapist can be available for the date and time of the deposition or court hearing wherein the therapist is ordered by the court. Reminder: A subpoena in which the client provided the therapist as a potential witness shall be billed in full for all court related activity.

All court fees must be received by cashierʼs check 7 days prior to the scheduled court date. Should the court, calendar the hearing for another date, the therapist must be re-issued a new subpoena/order with the new court hearing date.

Should the therapists be on vacation, the party initiating the court order must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena or order.

( CLIENTS WILL BE REQUESTED TO E-SIGN AND AGREE THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.)

Policy for Communication Outside of Sessions:

In our therapeutic journey together, your voice and reflections are immensely valued. I understand the importance of capturing your thoughts and feelings as they arise and encourage you to continue this reflective practice. Please consider any communications outside our sessions—whether they are emails, texts, or lengthy updates—as a secure 'parking lot' for your thoughts, a space where they are safely held until our next meeting.

While your communications are received with the utmost respect, please understand that due to the focused nature of our therapeutic work and time constraints, I may not always read each message immediately or in detail outside our scheduled sessions. This practice in no way diminishes the importance of your communications. Should there be specific elements from your messages that you wish to highlight or ensure are addressed, I invite you to bring them to my attention during our session. This approach ensures that our scheduled session time remains a focused and dedicated space for the real-time exploration and processing of your reflections, turning each insight into a stepping stone for your growth.

To honor the integrity of our session time, the therapist may allocate a portion of the beginning of your session to review any significant updates or reflections you've provided. Be aware that this might reduce the face-to-face time we have in that session, but it is intended to ensure that your most pressing thoughts and concerns are addressed promptly.

If you feel the need for more immediate support or wish to have a more extensive exploration of your reflections outside our regular sessions, you are welcome to request an additional session. This way, we can honor your journey's pace and provide the attentive space needed for your ongoing exploration and healing.

Please be aware that any additional communications, case management, letters/documentation, follow-up, or work/support conducted outside of our regular sessions will be billed at a pro-rated out-of-pocket fee. The fee will be determined based on the time required to provide these additional services.

example: Phone calls, email correspondence, text messages, or portal messages (including crisis consultation) that takes more than 5 minutes in length and occurs outside of a session (cumulatively within one business day) to read and/or respond to

$160 for 30 minutes, $75 for up to 15 minutes

There is no charge related to brief contact for scheduling purposes only.

Administrative Communication Policy

For the efficient management of our therapy services, we have established specific channels for cancellations and administrative queries.

Cancellations: To request, cancel, or reschedule an appointment, please use our client portal or the scheduling link provided. This ensures that your request is processed promptly and allows for better coordination of available session times.

Administrative Inquiries: For all logistical questions, scheduling concerns, billing inquiries, or coordination of services, kindly direct your communication to our office administration via the designated office email office@yaarahtherapy.org or portal. This channel is specifically set up to handle such queries efficiently, ensuring that your needs are addressed quickly and accurately.

Please refrain from directly contacting the provider for these matters. This helps maintain a structured and focused therapeutic environment and allows the provider to dedicate their time and attention to clinical work and client care.

Optional Reminders

Text and email reminders are available. This is done as a courtesy and only if you consent to receive such communication by providing us with your email address and cell number. It remains your sole responsibility to keep track of and timely attend all scheduled therapy appointments, whether you receive the text or email reminder. If you are unsure about your upcoming appointments, you can log into the portal to view and manage upcoming appointments or contact our office to clarify scheduling at office@yaarahtherapy.org

Social Media & Communication

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Your provider does not accept friend or contact requests from current or former clients on any social networking site. Adding clients as friends or contacts on these sites can compromise your 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 in your appointment. You are welcome to follow our public practice and wellness page on instagram @yaarah.therapy and Guided Meditation Soundcloud https://www.yaarahtherapy.org/...

You are welcome to leave your positive feedback/review on our yelp or google pages “Yaarah Therapy & Wellness Services” To respect your confidentiality, we will not reply/confirm/deny you are/ever were a client.

Telehealth Consent “Telehealth” (also known as “Video Therapy” and “Telephone Counseling”) involves the delivery of psychotherapy counseling services using electronic communications, information technology or other means between a mental health clinician and a client who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or education, and may include, but is not limited to: Video Therapy: counseling sessions provided via video conferencing; Telephone Counseling: counseling sessions provided via telephone ; Electronic transmission of clinical records, photo images, personal health information or other data between a client and a Provider; Interactions between a client and Provider via audio, video and/or data communications; and Use of output data from clinical devices, sound and video files.

The vendor of the electronic systems used in the provision of Video Therapy Services has represented that it incorporates industry standard network and software security protocols to protect the privacy and security of health information.

STATEMENT OF POTENTIAL RISKS AND BENEFITS

Potential Benefits of Telehealth Services:

Can be easier and more efficient for you to access clinical care and treatment from a Provider.

You can obtain clinical care and treatment at times that are convenient for you.

You can interact with a Provider without the necessity of an in-office appointment.

Potential Risks of Telehealth Services:

Information transmitted to your Provider may not be sufficient to allow for appropriate clinical decision making by the Provider.

The inability of your Provider to conduct certain tests or assessments in-person may in some cases prevent the Provider from providing a diagnosis or treatment or from identifying the need for emergency clinical care or treatment for you.

Your Provider may not able to provide clinical treatment for your particular condition via Video Therapy or Telephone Counseling. You may be required to seek alternative care. In this case, your Provider would offer you referral suggestions and resources to the best of her/his ability.

Delays in clinical evaluation/treatment could occur due to failures of the technology. Security protocols or safeguards could fail causing a breach of privacy. If this were to occur, your provider would notify you promptly. Given regulatory requirements in certain jurisdictions, your Provider’s treatment options may be limited.

By accepting this Consent to Telehealth Services, you acknowledge your understanding and agreement to the following:

I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By signing this form, I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the [Informed Consent Form or Statement of Disclosures] I received from my therapist also apply to my Telehealth services.

2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.

3. I understand that miscommunication between myself or my child/dependent and the therapist may occur via Telehealth.

4. I understand that there is a risk of being overheard by persons near me or my child/dependent and that I am responsible for ensuring that I or my child/dependent join from a location that is private and free from distractions or intrusions.

5. I understand the need to participate in Telehealth Services from a secure, private location to the best of my ability, and it is recommended that headphones are worn regardless of the location. I will communicate any privacy limitations to the Therapist prior to or at the beginning of the session.

6. I understand that at the beginning of each Telehealth session my therapist is required to verify my and/or my child/dependent's identity and current location.

7. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if the therapist believes I or my child/dependentwould be better served by in-person therapy or a different therapist able to offer services more specific to my or my child/dependent's needs, the therapist will discuss this with me and refer me or my child/dependent to in-person services or other therapists who can provide such services.

8. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues/needs, there is no guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I or my child/dependent may benefit from Telehealth, results cannot be guaranteed or assured.

9. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.

10. I agree that I will not, nor will my child/dependent use any computers, tablets, phones, recording devices, or other electronic devices for video or audio recordings, pictures, or monitoring.

11. I have discussed/reviewed the fees charged for Telehealth with the therapist and agree to them [or for insurance patients: I have discussed with my therapist and agree that my therapist will bill my insurance plan for Telehealth and that I will be billed for any portion that is the patient’s responsibility (e.g. co-payments)], and I have been provided with this information in the [Informed Consent Form or Payment Agreement Form].

12. I understand that the therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that the therapist may not be able to assist me or my child/dependent in an emergency situation. If I or my child/dependent require emergency care, I understand that I may call 911, local crisis response, or proceed to the nearest hospital emergency room for immediate assistance.

100% Police-Free / Anti-carceral Support Lines

Call BlackLine (800) 604-5841 Available 24/7 ”Call BlackLine provides a space for peer support, counseling, reporting of mistreatment, witnessing and affirming the lived experiences for folxs who are most impacted by systematic oppression with an LGBTQ+ Black Femme Lens. Call BlackLine prioritizes BIPOC (Black, Indigenous, and People of Color). By us for us.”

Thrive Lifeline Text “THRIVE” to 313-662-8209 Available 24/7 through text ”If you’re experiencing a mental health crisis and need to chat with a qualified crisis responder, we are here for you. If you are an underrepresented individual (person of color, LGBTQ2S+, person living with disabilities, neurodiverse, and/or other marginalized identities), and experiencing obstacles because of (or simply have questions about) your identities, we want to help you navigate those."

Trans Life Line (877) 565-8860 Available 24/7 ”Trans Lifeline provides trans peer support for our community that’s been divested from police since day one. We’re run by and for trans people.”

Wildflower Alliance (888) 407-4515 [Monday through Thursday] PST: 4pm to 6pm / EST: 7pm to 9pm [Friday through Sunday] PST: 4pm-7pm / EST: 7pm-10pm ”A peer support line (sometimes referred to as a ‘warmline’) is a private phone line that you can call to get support, ask about resources, connect with another person who can relate or has ‘been there’, or just talk. Our peer support line is answered by a trained peer supporter who has their own first-hand experience with psychiatric diagnosis, trauma, addiction, and/or other interrupting challenges. This line does not collect personal information, perform assessment, or call crisis or the police.”

Fireside Project (623) 473-7433 (call or text) Everyday 11am-1pm ”The psychedelic peer support line provides emotional support during and after psychedelic experiences.”

StrongHearts Native Helpline (844) 762-8483 Available 24/7 ”StrongHearts Native Helpline is a 24/7 safe, confidential and anonymous domestic and sexual violence helpline for Native Americans and Alaska Natives, offering culturally-appropriate support and advocacy.”

LGBTQ National Hotline 888-843-4564 (general, call or online chat) 888-234-7243 (senior-specific) 800-246-7743 (youth-specific, 25-and-under) 888-688-5428 (coming out support) [Monday through Friday] PST: from 1pm to 9pm [Saturday] PST: from 9am to 2pm “All of our support volunteers identify as part of the LGBTQIA+ family, and are here to serve the entire community, by providing free & confidential peer-support, information, and local resources through national hotlines and online programs.“

13. It is my duty to inform the Therapist of other in-person or electronic interactions regarding my care or my child/dependent's care that I or my child/dependent may have with other health care providers.

14. I agree to the use of electronic communications (I.e. via video, phone, text, email, and/or secure portal messenger) regarding care/services; this includes reminders, invoices, receipts, and telehealth link for each service to be provided to the service attendee/client/responsible party.

I hereby give my informed consent for the use of Video Therapy and/or Telephone Counseling, Text, Email, and secure messenger via client portal in my own or my child/dependent's mental health care/telehealth services.

I hereby authorize my Therapist to use Video Therapy and/or Telephone Counseling in the course of my or my clind/dependent'sdiagnosis and/or treatment.

THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.

I have read and understand the information provided above, and understand that I have the right to have all my questions regarding this information answered to my satisfaction.

Cancellation Policy

At Yaarah Therapy & Wellness Services, we deeply value the commitment made by you, your therapist, and the broader community we serve. Each scheduled therapy session is more than a discussion; it represents a thoughtful allocation of resources, meticulous preparation, and personalized care. When we reserve a session for you, it encompasses dedicated time, preparatory and follow up efforts, and administrative tasks, all tailored to your needs. Hence, a cancelled appointment has a ripple effect - impacting you, your therapist, and others who could have benefited from that slot.

Policy for Cancellations with Less Than 48-Hour Notice

Life's unpredictability is something we understand and empathize with. Nonetheless, cancellations made with less than 48 hours' notice present challenges. They prevent us from reallocating your reserved time to others in need, such as current clients, those on our waiting list, or individuals with urgent clinical needs.

This cancellation policy is not intended as a penalty, but as a necessary measure to ensure we can maintain high-quality care for all clients. We wish to assure you that this policy is not about penalization but about maintaining a viable practice and service quality. We understand that unforeseen events can happen. As a courtesy, we provide two (2) discounted late-cancellation fees per calendar year.

Our policy is straightforward:

No Shows, cancellations, and rescheduled sessions will incur a full charge if not notified at least 48 hours in advance.

For contract clients, this fee is $200.

This policy is in place because your reserved time is a commitment made to you, exclusively.

Late arrivals may result in a shortened session, but the full session fee applies.

Late cancellation or no-show fees will be charged to the card on file on the day of the missed service/cancellation.

As a courtesy, three (3) discounted late-cancellation fees will be available per calendar year. Enter Coupon code: LATEFREE50-2024 into invoice to redeem discount

For the efficient management of our therapy services, we have established specific channels for cancellations:

To request, cancel, or reschedule an appointment, please use our client portal or the scheduling link provided. This ensures that your request is processed promptly and allows for better coordination of available session times.

Termination

Ending relationships can be difficult, so it is a good idea to plan for your termination, in collaboration with your therapist in order to achieve some closure. The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan, needs, and the progress you achieve. Your therapist will discuss/inform you of a plan for termination/transitions as you approach the completion of your treatment goals, if it is determined that the psychotherapy is not being effectively used, if you are in default on payment, do not return forms required for services, if there is a conflict of interest, or if you or your therapist determines that you are not benefiting from treatment. Either party may elect to initiate a discussion of your treatment alternatives, which may include, among other possibilities, referrals, changing your treatment plan, or ending your therapy services. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

Optional Reminders

Text and email reminders are available. This is done as a courtesy and only if you consent to receive such communication by providing us with your email address and cell number. It remains your sole responsibility to keep track of and timely attend all scheduled therapy appointments, whether you receive the text or email reminder. If you are unsure about your upcoming appointments, you can log into the portal to view and manage upcoming appointments or contact our office to clarify scheduling at office@yaarahtherapy.org

(PROSPECTIVE CLIENTS WILL BE REQUESTED TO E-SIGN AND AGREE THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.)

You are receiving this consent form because you are a current client or a current client has indicated that you will be responsible for the cost of services the below named client.

Thank you for choosing Yaarah Therapy & Wellness Services for care. We ask that you read and complete this form to acknowledge and agree to accept financial responsibility for services rendered by the therapist to the client. The section below is to capture payment information for any financial responsibility owe throughout the course of treatment.

Financial responsibility terms

I agree that I, , am legally financially responsible and agree to pay to the Provider all fees, charges and expenses incurred by the client or owed to Yaarah Therapy & Wellness Services in connection to the therapist providing care to Client.

I understand that should there be changes in financial arrangement or service fees, Yaarah Therapy & Wellness and/or my provider will provide at least 2 weeks notice of the change.

I understand that if I am seeking reimbursement from insurance, it is my responsibility to contact my insurer to confirm out-of-network coverage and rates for my out of pocket expenses for a provider who is a Licensed Marriage and Family Therapist. I also understand that I am responsible for requesting and submitting superbills to my insurer.

I acknowledge and agree that I am ultimately responsible for the full payment, paid prior to or on the day of service to the Provider for any and all services rendered by Provider to Client.

Initial:

I understand that it is the client/my responsibility to inform the provider of when a payment method update form is necessary in order to change or update the payment method on file; this can be done at any time.

I understand that cash and check are not accepted methods of payment.

I understand that regardless of how I am paying for psychotherapy, it is required by Yaarah Therapy & Wellness Services to have at least one valid card/payment method on file at all times and I will not be provided services if this agreement is not honored.

If I would like to use any other alternative payment method (ie. IvyPay, Zelle, Square, Paypal, AplePay, GooglePay, ACH, Prepaid session), I understand that payment must be received in full prior to the scheduled service and receipt must be confirmed with provider. Otherwise, the card on file will be charged.

I understand that payment is otherwise automatically charged to the card on file on the day of or before the service, if there is not a pre-payment or agreed upon arrangement with the therapist. Any other third-party payee arrangements will be formally arranged and approved prior to the onset of services, and/or as needed during the course of treatment. This will be confirmed in writing and reflected on the client account.

I understand that clients are under no obligation to make additional contributions, including gratuity or donations. If I choose to provide an additional payment in the form of gratuity or a donation, it is my choice. I understand that, while these donations are not tax-deductible, they are incredibly valuable in funding the "Nourishing Roots of Resilience Scholarship" for individuals who might otherwise be unable to access our services.

Initial:

I acknowledge that all charges are non-refundable and that I will not dispute or initiate a chargeback for any payments made for services.

I agree to keep at least one current credit or debit card on file for all payments.

I acknowledge and accept full responsibility for ensuring the availability of sufficient funds to cover all charges.

I authorize Provider to send email or text receipts of payments made.

I understand that if a payment declines/fails, reattempts will be initiated for the full payment and/or a portion thereof. A $30.00 service charge will be charged for any checks returned for any reason for special handling. Once an account becomes past due and late fees are assessed, you must pay past due charges, plus late fees to bring the account current and schedule appointments. Unpaid balance may result in late fees, assessed at the rate of $50 monthly on accounts with a delinquent balance of $50 or greater. Late fees will continue to be assessed every 30 days and are due the day after they have been assessed. No more than one late fee will be assessed in a 30 day period.

I acknowledge that if my account is past due, Yaarah Therapy & Wellness Services may be obligated to turn past due accounts over to a collection agency or seek collection with a civil court action. By signing below, you agree that Yaarah Therapy & Wellness Services may seek payment for your unpaid balance with the assistance of a collections agency. Should this occur, Yaarah Therapy & Wellness Services will provide the collection agency or Court with your name, address, phone number, and any other directory information, including dates of service or any other information requested by the collection agency or Court deemed necessary to collect the past due account. Yaarah Therapy & Wellness Services will not disclose more information than necessary to collect the past due account. Yaarah Therapy & Wellness Services will notify you of any intention to turn your account over to a collection agency or the Court by sending such notice to your last known address and/or email.

I acknowledge that should the Responsible Party/client fail to make payment, Responsible Party/client would be in default. Any late payment, non-payment, dispute, breach of agreement, or failure to pay fees for subsequent appointments will result in ethical termination of services due to non-payment. In this case, I will still owe the balance until settled in full.

Initial:

I, , authorize Yaarah Therapy & Wellness Services to charge my credit card on file for therapy or related services including services not covered by insurance for the provider. This may include sessions with the client, any collateral contact or communication with third parties regarding client treatment, additional administrative work, evaluations, reports, any time spent reviewing or producing documentation, products, payments/copayments, and Late Cancellation or No Show fees.

I acknowledge that this authorization will remain in effect until either the business or I provide a written request for termination, and there is no money owed. It is my responsibility to make this request at least 3 business days before the next scheduled charge or service date to avoid being charged again. If this agreement is terminated, services may also be terminated unless alternative financial arrangements have been made. Any changes to this agreement must be made in writing and signed by both parties. This agreement will be governed and interpreted according to the laws of the State of California.

I further acknowledge that by entering my card information into this form, Yaarah Therapy & Wellness Services will have no access to my complete card information, as this form is linked to the Square platform, which is encrypted and HIPAA compliant; only the last 4 digits of the card will be visible.

Initial:

I understand that this authorization is valid until cancelled it in writing and no balance is owed.

I understand that though this information is secured on an online password protected platform, and is unlikely to be tampered with, I agree to assume the risk if the file and/or credit card information is compromised.

I understand that the payment method I put on file may be charged by Yaarah Therapy & Wellness Services in order to settle any outstanding balances accrued by the above named client upon termination.

I understand that if a charge back fee is incurred, I will be responsible for those fees as the client/responsible party.

I agree that if I have concerns or questions about charges on my account, or if the charge fails to post to my account, I will contact Yaarah Therapy & Wellness Services for assistance.

Initial:

I understand and agree that a financially responsible party/payor for client's services who is not the client receiving services, may only have access to the minimum information necessary for billing purposes only, as they pertain to the above named client. I understand that I will not have access to any clinical or other personal information related to the client with the exception of scheduling (dates, times, session length, service type if necessary). I understand that I will need to ask the above named client directly if I require any clinical information unrelated directly to billing.

I understand that the clinician and Yaarah Therapy & Wellness Services will not mediate or be involved in any dispute related to the client and the third-party financial payor/responsible party, as it relates to paying for services or applicable fees.

Initial:

* Today's date

Finally, if I am assuming service payment responsibility for the client above who's name is listed in the printed area, and that client is someone other than myself, I understand that I am not entitled to information pertaining to confidential therapy sessions between the above client, the provider, and Yaarah Therapy & Wellness Services.

Initial:

Dear Parents and Guardians,

Thank you for choosing our services for your child or teenager. Your active participation and genuine concern for their well-being are not only noticed but also immensely valued. It's truly uplifting to work alongside parents/caregivers who are so involved in their young person's therapeutic journey.

First Session and Building Trust:

Initial sessions play a critical role in establishing a relationship of trust, curiosity, creativity, and safety with our young clients. During the first meeting, parents are invited to participate briefly for a warm introduction and smooth transition. Subsequently, the focus will be on spending one-on-one time with your child or teen to cultivate trust and mutual understanding.

Here's how we can collaboratively ensure a supportive and constructive therapeutic process:

1. Parental Insight & Intake:

* Your perspectives are invaluable. Please complete the intake forms in the secure client portal at least 24 hours prior to our first meeting, providing a comprehensive view of your child or teen's experiences and your interactions with them, to enrich understanding and guide the therapeutic journey.

2. Client Autonomy:

* Respecting the autonomy of our younger clients, especially those aged 12 and above, is crucial. It’s essential for me to have their direct consent for services and to ensure they have confidential access to their client portal. Kindly share their email address and cell phone number with us.

3. Virtual Session:

* All services will be virtual for the foreseeable future. While this may differ from traditional in-person sessions, there's a silver lining: being in a familiar environment allows us to explore and practice strategies that your young person can readily use at home outside of sessions. Their everyday comforts become valuable tools in our therapeutic journey, facilitating real-time learning and adaptation. Especially with neurodivergent youth, I prioritize creative approaches to ensure engaging virtual sessions. It is great if there is access to art supplies and some of their favorite things, water, and an optional snack. The Telehealth link is always emailed to the client 15 minutes prior to the session.

4. Ensuring a Private, Comfortable, and Safe Space:

* Confidentiality and a secure space are paramount in virtual sessions, similar to in-person ones. Your child or teen should be in a quiet, private room with the door closed and use headphones to maintain confidentiality and minimize distractions. Utilizing white noise near the door can also be beneficial, especially with thinner walls/doors.  

5. Upholding Trust and Confidentiality:

* Maintaining a sacred and secure space for your child or teen to freely express themselves is pivotal to effective therapy. This encompasses not only the sessions themselves but also all communications between the therapist and the young client. Therefore, sessions and communications — whether they be emails, messages, or any other form — should never be recorded, monitored, screens shotted, or intruded upon. This practice safeguards the integrity of our therapeutic relationship, upholds privacy and legal rights, and is crucial for building and sustaining trust, comfort, and efficacy throughout the therapeutic journey. Your adherence to these essential boundaries is greatly appreciated and fundamental to the progress we hope to achieve together.

6. Parental/ Caregiver Collateral Meetings:

* In navigating through this therapeutic journey with your child or teen, I recognize and deeply value the critical role parents/caregivers play. To ensure we are all aligned and supportive of their path, I offer opportunities for parental collateral meetings or phone call sessions, always threading carefully to balance involvement with respect for your child/teen's autonomy and confidentiality. Your insights are crucial and can significantly enhance our collective efforts to support their journey towards wellbeing.
I offer check-ins where we can discuss general progress, any pertinent concerns, and relevant updates, tailored to the unique needs and clinical recommendations for your young person. In addition, I provide check-in symptom questionnaire forms as a structured means for you to share updates and express concerns about symptoms or behaviors observed at home.
It's paramount to note that while I'm dedicated to a collaborative approach, the confidentiality and trust between me and your child or teen are of utmost importance. General progress and any concerns, informed by clinical judgment and with the knowledge of the client, will be shared while scrupulously respecting confidentiality boundaries. In the event of substantial concerns, rest assured that I will communicate them promptly.
Together, maintaining these boundaries, we can build a structured, yet flexible framework that allows your child or teen to safely and genuinely explore and express their experiences in therapy.

Thank you for your cooperation and understanding. Looking forward to a constructive and supportive journey together