Erik Young Counseling LLC
558 W. Uwchlan Ave, Suite #2, Exton, PA 19341
Phone 484-693-0582
Fax 484-631-0502
www.erikyoungcounseling.com
INFORMATION, AUTHORIZATION, & CONSENT TO
TREATMENT
Welcome to Erik Young Counseling
LLC. We are very pleased that you selected our facility
for your therapy, and we are sincerely looking forward to
assisting you. This document is designed to inform you
about what you can expect from your therapist or group leader,
policies regarding confidentiality and emergencies, and several
other details regarding your treatment here at Erik Young
Counseling LLC. Although providing this document is
part of an ethical obligation to our profession, more
importantly, it is part of our commitment to you to keep you
fully informed of every part of your therapeutic
experience. Please know that your relationship with your
therapist or group leader is a collaborative one, and we welcome
any questions, comments, or suggestions regarding your course of
therapy at any time.
Background Information, Theoretical Views, & Client
Participation
Information regarding your therapist's
educational background and experience may be found on our website
under his or her name. Please feel free to view that
information at www.erikyoungcounseling.com.
It is our belief that as people become
more aware accepting of themselves, they are more capable of
finding a sense of peace and contentment in their lives.
However, self-awareness and self-acceptance are goals that may
take a long time to achieve. Some clients need only a few
sessions to achieve these goals, whereas others may require
months or even years of therapy. As a client, you are in
complete control, and you may end your relationship with your
therapist/group leader at any point.
In order for therapy to be most
successful, it is important for you to take an active role.
This means working on the things you and your therapist talk
about both during and between sessions. This also means
avoiding any mind-altering substances like alcohol or
non-prescription drugs for at least eight hours prior to your
therapy sessions. Generally, the more of yourself you are
willing to invest, the greater the return.
Furthermore, it is our policy to only
see clients who we believe have the capacity to resolve their own
problems with our assistance. It is our intention to
empower you in your growth process to the degree that you are
capable of facing life's challenges in the future without your
therapist. We also don't believe in creating dependency or
prolonging therapy if the therapeutic intervention does not seem
to be helping. If this is the case, your therapist will
direct you to other resources that willbe of assistance to
you. Your personal development is our number one
priority. We encourage you to let us know if you feel that
transferring to another facility or another therapist is
necessary at any time. Our goal is to facilitate healing
and growth, and we are very committed to helping you in whatever
way seems to produce maximum benefit. If at any point you
are unable to keep your appointments or we don't hear from you
for one month, we will need to close your chart. However,
reopening your chart and resuming treatment is always an option.
Confidentiality & Records
Your communications with your
therapist will become part of a clinical record of treatment, and
it is referred to as Protected Health Information (PHI).
Your PHI will be kept in a file stored in a locked cabinet in our
locked office and Your PHI will be stored electronically with
Counsol.Com, a secure storage company who has signed a
HIPAA Business Associate Agreement (BAA). The BAA ensures that
they will maintain the confidentiality of your PHI in a
HIPAA compatible secure format using point-to-point, Federally
approved encryption.
There are a few other people who
may also have access to your PHI. The practice owner, Erik Young,
may review your case with your therapist in the interest of
providing you with the best possible care. As a licensed
clinician, Erik Young is also required to keep all information
about clients confidential. Additionally, one of our
administrative assistants or our business manager may need to
access your chart on occasion for business purposes only.
This might be to check for dates of services to file an insurance
claim (if applicable), to ascertain that all of the HIPAA
required documentation is located in the chart (occasional audit
of charts), or some other absolutely necessary business
practice. However, please know this would never include
reading any of your clinical notes. Additionally, each
business associate has signed a HIPAA enforced confidentiality
contract which spells out how confidential records must be
handled.
Your therapist will always keep
everything you say to him or her completely confidential, with
the following exceptions: (1) you direct your therapist to
tell someone else and you sign a "Coordination of Treatment"
form; (2) your therapist determines that you are a danger to
yourself or to others; (3) you report information about the abuse
of a child, an elderly person, or a disabled individual who may
require protection; or (4) your therapist is ordered by a judge
to disclose information. In the latter case, your
therapist's license does provide him or her with the ability to
uphold what is legally termed "privileged communication."
Privileged communication is your right as a client to have a
confidential relationship with a counselor. If for some
unusual reason a judge were to order the disclosure of your
private information, this order can be appealed. We cannot
guarantee that the appeal will be sustained, but we will do
everything in our power to keep what you say confidential.
Please note that in couple's counseling,
your therapist does not agree to keep secrets. Information
revealed in any context may be discussed with either
partner.
Professional Relationship
Your relationship with your therapist
has to be different from most relationships. It may differ in how
long it lasts, the objectives, or the topics discussed. It
must also be limited to only the relationship of therapist and
client. If you and your therapist were to interact in any
other ways, you would then have a "dual relationship," which
could prove to be harmful to you in the long run and is,
therefore, unethical in the mental health profession. Dual
relationships can set up conflicts between the therapist's
interests and the client's interests, and then the client's
(your) interests might not be put first. In order to offer
all of our clients the best care, your therapist's judgment needs
to be unselfish and purely focused on your needs. This is
why your relationship with your therapist must remain
professional in nature.
Additionally, there are important
differences between therapy and friendship. Friends may see your
position only from their personal viewpoints and experiences.
Friends may want to find quick and easy solutions to your
problems so that they can feel helpful. These short-term
solutions may not be in your long-term best interest. Friends do
not usually follow up on their advice to see whether it was
useful. They may need to have you do what they advise. A
therapist offers you choices and helps you choose what is best
for you. A therapist helps you learn how to solve problems better
and make better decisions. A therapist's responses to your
situation are based on tested theories and methods of change.
You should also know that therapists are
required to keep the identity of their clients confidential. As
much as your therapist would like to, for your confidentiality he
or she will not address you in public unless you speak to him or
her first. Your therapist also must decline any invitation
to attend gatherings with your family or friends. Lastly,
when your therapy is completed, your therapist will not be able
to be a friend to you like your other friends. In sum, it
is the duty of your therapist to always maintain a professional
role. Please note that these guidelines are not meant to be
discourteous in any way, they are strictly for your long-term
protection.
Statement Regarding Ethics, Client Welfare &
Safety
Erik Young Counseling LLC assures
you that our services will be rendered in a professional manner
consistent with the ethical standards of the American
Psychological Association and/or the American Counseling
Association and/or the National Association of Social Workers
and/or the American Association for Marriage and Family
Therapy. If at any time you feel that your therapist is not
performing in an ethical or professional manner, we ask that you
please let him or her know immediately. If the two of you
are unable to resolve your concern, please contact Erik Young
(e.g., Practice Owner) at 484-693-0582.
Due to the very nature of psychotherapy, as
much as we would like to guarantee specific results regarding
your therapeutic goals, we are unable to do so. However,
your therapist, with your participation, will work to achieve the
best possible results for you. Please also be aware that
changes made in therapy may affect other people in your
life. For example, an increase in your assertiveness may
not always be welcomed by others. It is our intention to
help you manage changes in your interpersonal relationships as
they arise, but it is important for you to be aware of this
possibility nonetheless.
Additionally, at times people find that they
feel somewhat worse when they first start therapy before they
begin to feel better. This may occur as you begin
discussing certain sensitive areas of your life. However, a
topic usually isn't sensitive unless it needs attention.
Therefore, discovering the discomfort is actually a
success. Once you and your therapist are able to target
your specific treatment needs and the particular modalities that
work the best for you, help is generally on the way.
For the safety of all
our clients, their accompanying family members and children, and
our therapists and staff, Erik Young Counseling LLC
maintains a zero tolerance weapons policy. No weapon of any
kind is permitted on the premises, including guns, explosives,
ammunition, knives, swords, razor blades, pepper spray, garrotes,
or anything that could be harmful to yourself or others.
Erik Young Counseling LLC reserves the right to contact
law enforcement officials and/or terminate treatment with any
client who violates our weapons policy.
TeleMental Health Statement
In our ever-changing technological
society, there are several ways we could potentially communicate
and/or follow each other electronically. It is of utmost
importance to us that we maintain your confidentiality, respect
your boundaries, and ascertain that your relationship with your
therapist remains therapeutic and professional.
TeleMental Health is defined as follows:
"TeleMental Health means the mode of delivering services via
technology-assisted media, such as but not limited to, a
telephone, video, internet, a smartphone, tablet, PC desktop
system or other electronic means
using appropriate encryption
technology for electronic health information. TeleMental Health
facilitates client self-management and support
for clients and includes synchronous interactions and
asynchronous store and forward transfers."
TeleMental Health is a relatively new concept despite the fact
that many therapists have been using technology-assisted media
for years. Breaches of confidentiality over the past decade have
made it evident that Personal Health Information (PHI) as it
relates to technology needs an extra level of protection.
Additionally, there are several other factors that need to be
considered regarding the delivery of TeleMental Health services
in order to provide you with the highest level of care.
Therefore, our therapists have completed specialized training in
TeleMental Health. We have also developed several policies and
protective measures to assure your PHI remains
confidential. These are discussed below.
The Different Forms of Technology-Assisted Media Explained
Telephone via Landline:
It is important for you to know that
even landline telephones may not be completely secure and
confidential. There is a possibility that someone could
overhear or even intercept your conversations with special
technology. Individuals who have access to your telephone or your
telephone bill may be able to determine who you have talked to,
who initiated that call, and how long the conversation lasted. If
you have a landline and you provided us with that phone number,
we may contact you on this line from our own landline in our
office or from a cell phone, typically only for purposes of
setting up an appointment if needed. If this is not an
acceptable way to contact you, please let your therapist know.
Telephone conversations (other than just setting up appointments)
are billed at your therapist's hourly rate.
Cell phones:
In addition to landlines, cell phones
may not be completely secure or confidential. There is also
a possibility that someone could overhear or intercept your
conversations. Be aware that individuals who have access to your
cell phone or your cell phone bill may be able to see who you
have talked to, who initiated that call, how long the
conversation was, and where each party was located when that call
occurred. However, we realize that most people have and utilize a
cell phone. We may also use a cell phone to contact you,
typically only for purposes of setting up an appointment if
needed. Additionally, your therapist may keep your phone
number in his/her cell phone, but it will be listed by your
initials only and his/her phone is password protected. If
this is a problem, please let your therapist know, and you he/she
will be glad to discuss other options. Telephone conversations
(other than just setting up appointments) are billed at your
therapist's hourly rate.
Text Messaging:
Text messaging is not a secure means of
communication and may compromise your confidentiality.
However, we realize that many people prefer to text because it is
a quick way to convey information. Nonetheless, please
know that it is our policy to utilize this means of communication
strictly for appointment confirmations. Please do not
bring up any therapeutic content via text to prevent compromising
your confidentiality. You also need to know that we are
required to keep a copy or summary of all texts as part of your
clinical record that address anything related to therapy.
Email:
We utilize a secure email platform that
is hosted by Counsol as part of your client portal. We
have chosen this technology because it is encrypted to the
federal standard, HIPAA compatible, and has signed a HIPAA
Business Associate Agreement (BAA). The BAA means that the
company is willing to attest to HIPAA compliance and assume
responsibility for keeping your PHI secure. If we choose to
utilize emailing as part of your treatment, we encourage you to
also utilize this kind of software for protection on your end.
Otherwise, when you reply to one of your therapist's emails,
everything you write in addition to what he/she has written to
you (unless you remove it) will no longer be secure. Our
encrypted email service only works to send information and does
not govern what happens on your end.
We also strongly suggest that you only
communicate through a device that you know is safe and
technologically secure (e.g., has a firewall, anti-virus software
installed, is password protected, not accessing the internet
through a public wireless network, etc.). If you are in a crisis,
please do not communicate this to us via email because we may not
see it in a timely matter. Instead, please see below under
"Emergency Procedures."
Email is billed at your therapist's
hourly rate for the time she or he spends reading and responding
to them. See the Fee schedule for more information.
If you are in a crisis, please do not communicate this to
us via email because we may not see it in a timely matter.
Instead, please see below under "Emergency Procedures." Finally,
you also need to know that we are required to keep a copy or
summary of all email as part of your clinical recordthat address
anything related to therapy.
Blogs:
We may post counseling
information/therapeutic content on our professional blog.
If you have an interest in following our blog, please feel free
to do so. However, please be mindful that the general public may
see that you're following Erik Young Counseling LLC's
blog. Once again, maintaining your confidentiality is a
priority.
Video Conferencing (VC):
Video Conferencing is an option for your therapist to conduct
remote sessions with you over the internet where you may speak to
one another as well as see one another on a screen. We utilize
Counsol.com's VC platform. This VC platform is encrypted
to the federal standard, HIPAA compatible, and has signed a HIPAA
Business Associate Agreement (BAA). The BAA means that
Counsol.com is willing to attest to HIPAA compliance and
assumes responsibility for keeping your VC interaction secure and
confidential. If you and your therapist choose to utilize this
technology, your therapist will give you detailed directions
regarding how to log-in securely. We also ask that you please
sign on to the platform at least five minutes prior to your
session time to ensure you and your therapist get started
promptly. Additionally, you are responsible for initiating the
connection with your therapist at the time of your appointment.
We strongly suggest that you only
communicate through a computer or device that you know is safe
(e.g., has a firewall, anti-virus software installed, is password
protected, not accessing the internet through a public wireless
network, etc.).
Website Portal:
We have a client portal that is accessible through our website at
Counsol.com, which is powered by Counsol.com.
Counsol.com ensures this portal is encrypted to the
federal standard, HIPAA compatible, and has agreed to sign a
HIPAA Business Associate Agreement (BAA). The BAA means that
Counsol is willing to attest to HIPAA compliance and
assumes responsibility for keeping our interactions secure and
your PHI confidential. If we choose to utilize this technology,
we will give you detailed directions regarding how to log-in
securely. We also strongly suggest that you only communicate
through a device that you know is safe (e.g., has a firewall,
anti-virus software installed, is password protected, not
accessing the internet through a public wireless network, etc.).
Additionally, through the client portal,
you have the option of receiving text and/or email reminders of
your appointments with us and/or billing information. If you
would like this service, please check the "Website Portal" option
at the end of the document.
Recommendations to Websites or Applications (Apps):
During the course of our treatment, your
therapist may recommend that you visit certain websites for
pertinent information or self-help. She or he may also recommend
certain apps that could be of assistance to you and enhance your
treatment. Please be aware that websites and apps may have
tracking devices that allow automated software or other entities
to know that you've visited these sites or applications. They may
even utilize your information to attempt to sell you other
products. Additionally, anyone who has access to the device you
used to visit these sites and/or apps, may be able to see that
you have been to these sites by viewing the history on your
device. Therefore, it is your responsibility to decide if you
would like this information as adjunct to your treatment or if
you prefer that your therapist does not make these
recommendations. Please let your therapist know by checking (or
not checking) the appropriate box at the end of this document.
Electronic Record Storage:
Your communications with us will become
part of a clinical record of treatment, and it is referred to as
Protected Health Information (PHI). Your PHI will be stored
electronically with Counsol.com, a secure storage company
who has signed a HIPAA Business Associate Agreement (BAA). The
BAA ensures that they will maintain the confidentiality of your
PHI in a HIPAA compatible secure format using point-to-point,
federally approved encryption.
Your Responsibilities for Confidentiality & TeleMental
Health
Please communicate only through devices
that you know are secure as described above. It is also your
responsibility to choose a secure location to interact with
technology-assisted media and to be aware that family, friends,
employers, co-workers, strangers, and hackers could either
overhear your communications or have access to the technology
that you are interacting with. Additionally, you agree not to
record any TeleMental Health sessions.
In Case of Technology Failure
During a TeleMental Health session, you
and your therapist could encounter a technological failure. The
most reliable backup plan is to contact one another via
telephone. Please make sure you have a phone with you, and your
therapist has that phone number.
If you and your therapist get
disconnected from a video conferencing or chat session, end and
restart the session. If you are unable to reconnect within
ten minutes, please call your therapist.
If you and your therapist are on a phone
session and you get disconnected, please call your therapist back
or contact her or him to schedule another session. If the issue
is due to your therapist's phone service, and the two of
you are not able to reconnect, she/he will not charge you for
that session.
Limitations of TeleMental Health Therapy Services
TeleMental Health services should not be
viewed as a complete substitute for therapy conducted in our
office, unless there are extreme circumstances that prevent you
from attending therapy in person. It is an alternative form
of therapy or adjunct therapy, and it involves limitations.
Primarily, there is a risk of misunderstanding one another when
communication lacks visual or auditory cues. For example, if
video quality is lacking for some reason, your therapist might
not see a tear in your eye. Or, if audio quality is lacking, he
or she might not hear the crack in your voice that he or she
could have easily picked up if you were in our office.
There may also be a disruption to the
service (e.g., phone gets cut off or video drops). This can be
frustrating and interrupt the normal flow of personal
interaction.
Please know that we have the utmost
respect and positive regard for you and your wellbeing. We would
never do or say anything intentionally to hurt you in any way,
and we strongly encourage you to let your therapist know if
something she or he has done or said upset you. We invite you to
keep the communication with your therapist open at all times to
reduce any possible harm.
Face-to Face Requirement
If you and your therapist agree that
TeleMental Health services are the primary way that you
and your therapist choose to conduct sessions, we require one
face-to-face meeting at the onset of treatment. We prefer for
this initial meeting to take place in our office. If that is not
possible, we can utilize video conferencing as described above.
During this initial session, your therapist will require you to
show a valid picture ID and another form of identity verification
such a credit card in your name. At this time, you will also
choose a password, phrase, or number which you will use to
identify yourself in all future sessions. This procedure prevents
another person from posing as you.
Consent to TeleMental Health Services
Please check the TeleMental Health
services you are authorizing your therapist to utilize for your
treatment or administrative purposes. You and your therapist will
ultimately determine which modes of communication are best for
you. However, you may withdraw your authorization to use any of
these services at any time during the course of your treatment
just by notifying us in writing. If you do not see an item
discussed previously in this document listed for your
authorization below, this is because it is built-in to our
practice, and we will be utilizing that technology unless
otherwise negotiated by you.
Texting
Email
Video Conferencing
Website Portal
Electronic Chat Forum
Recommendations to Websites or Apps
In summary, technology is constantly changing, and there are
implications to all of the above that we may not realize at this
time. Feel free to ask questions, and please know that we
are open to any feelings or thoughts you have about these and
other modalities of communication and treatment.
Communication Response Time
Our practice is considered to be an
outpatient facility, and we are set up to accommodate individuals
who are reasonably safe and resourceful. We do not carry
beepers nor are we available at all times. If at any time
this does not feel like sufficient support, please inform your
therapist, and he or she can discuss additional resources or
transfer your case to a therapist or clinic with 24-hour
availability. We will return phone calls, texts, email,
etc.) within 24 hours. However, we do not return calls on
weekends or holidays. If you are having a mental health emergency
and need immediate assistance, please follow the instructions
below.
In Case of an Emergency
If you have a mental health emergency,
we encourage you not to wait for a call back, but to do one or
more of the following:
Call Valley Creek Crisis Center:
877-918-2100
Call Lifeline at (800) 273-8255
(National Crisis Line)
Call 911.
Go to the emergency room of your
choice.
If you & your therapist decide to
include TeleMental Health as part of your treatment, there are
additional procedures that we need to have in place specific to
TeleMental Health services. These are for your safety in case of
an emergency and are as follows:
You understand that if you are
having suicidal or homicidal thoughts, experiencing psychotic
symptoms, or in a crisis that we cannot solve remotely, we may
determine that you need a higher level of care and TeleMental
Health services are not appropriate.
We require an Emergency Contact
Person (ECP) who we may contact on your behalf in a
life-threatening emergency only. Please write this person's name
and contact information below. Either you or we will verify that
your ECP is willing and able to go to your location in the event
of an emergency. Additionally, if either you, your ECP, or we
determine necessary, the ECP agrees take you to a hospital. Your
signature at the end of this document indicates that you
understand we will only contact this individual in the extreme
circumstances stated above. Please list your ECP here:
Name: ______________________________________________ Phone:
_______________________
You agree to inform your therapist
of the address where you are at the beginning of every TeleMental
Health session.
You agree to inform your therapist
of the nearest mental health hospital to your primary location
that you prefer to go to in the event of a mental health
emergency (usually located where you will typically be during a
TeleMental Health session). Please list this hospital and contact
number here:
Hospital: ____________________________________________
Phone: _______________________
Structure and Cost of Sessions
We offer primarily face-to-face therapy
sessions. However, based on your treatment needs, your therapist
may provide phone, or video conferencing (TeleMental Health).
The structure and cost of both in-person sessions and
TeleMental Health is $150 per 50 minute session, and/or $220 per
90 minute therapy session, unless otherwise negotiated by your
insurance carrier. The fee for each session will be due at
the beginning of the session. Cash, personal checks, Visa,
MasterCard, Discover, or American Express are acceptable for
payment, and we will provide you with a detailed receipt of
payment. The receipt of payment may also be used as a
statement for insurance if applicable to you. Please note
that there is a $30 fee for any returned checks.
Phone calls, texting, and emails (other than
just setting up appointments) are billed at your therapist's
hourly rate for the time he/she spends reading and responding. We
require a credit card ahead of time for TeleMental Health therapy
for ease of billing. Please sign the Credit Card Payment Form,
which was sent to you separately and indicates that we may charge
your card without you being physically present. Your credit card
will be charged at the conclusion of each TeleMental Health
interaction. Again, this includes any therapeutic interaction
other than setting up appointments.
Insurance companies have many rules and
requirements specific to certain plans. Unless otherwise
negotiated, it is your responsibility to find out your insurance
company's policies and to file for insurance reimbursement when
submitting for out of network reimbursement. As mentioned above,
we will be glad to provide you with a statement for your
insurance company and to assist you with any questions you may
have in this area. We will submit for all in network insurance
billing.
Cancellation Policy
In the event that you are unable
to keep either a face-to-face appointment or a TeleMental Health
appointment, you must notify your therapist at least 24 hours in
advance. If such advance notice is not received, you will
be financially responsible for the session you missed.
Please note that insurance companies do not reimburse for missed
sessions.
Our Agreement to Enter into a Therapeutic
Relationship
Please print, date, and sign your name below
indicating that you have read and understand the contents of this
"Information, Authorization and Consent to Treatment" form as
well as the Health Insurance Portability and Accountability Act
(HIPAA) Notice of Privacy Practices" provided to you
separately. Your signature also indicates that you agree to the
policies of your relationship with your therapist and/or group
leader, and you are authorizing your therapist and/or group
leader to begin treatment with you. Please note that this updated
"Information, Authorization & Consent to Treatment" replaces
any previously signed informed consents.
We are sincerely looking forward to facilitating you
on your journey toward healing and growth. If you have any
questions about any part of this document, please ask your
therapist.
__________________________________________________
_________________
Client Name (Please
Print)
Date
__________________________________________________
Client
Signature
If Applicable:
__________________________________________________
_________________
Parent's or Legal
Guardian's Name (Please Print)
Date
__________________________________________________
Parent's or Legal Guardian's
Signature
__________________________________________________
_________________
Parent's or Legal
Guardian's Name (Please Print)
Date
__________________________________________________
Parent's or Legal Guardian's
Signature