APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. You
The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
A $10.00 service charge will be charged for any checks returned for any reason for special handling.
Cancellations and re-scheduled session 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. If you are late for a session, you may lose some of that session time.
The acknowledgment of this document entitles you to have access to services and makes you responsible for the fees associated with such services; disputed charges will be presented with this document as an acknowledgment to your responsibility to pay for services.
LAWYERS:
This document acknowledges that if legal actions were to be taken and the potential for actions such as deposition to occur, the standard fee per hour assessed to lawyers and anyone associated is $525 an hour for time spent but not limited to collecting/gathering, preparing, time-spent traveling, time-spent over the phone, e-mail or facsimile; Time-spent will be invoiced and provided to said party prior to initiating any legal process.
TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voicemail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
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Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that 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 when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION
I 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 for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
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 visual and olfactory 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
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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 he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source. You will be responsible for any balances to your account and payments made from your account.Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
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Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
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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.
This notice went into effect on September 20, 2013
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
The following information is provided to clients who are seeking TeleMental health therapy. This document covers your rights, risks and benefits associated with receiving services, my policies, and your authorization. Please read this document carefully, note any questions you would like to discuss, and sign. TeleMental Health Defined: TeleMental health means the remote delivering of health care services via technology-assisted media. This includes a wide array of clinical services and various forms of technology. The technology includes but is not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means. The delivery method must be secured by two way encryption to be considered secure. Synchronous (at the same time) secure video chatting is the preferred method of service delivery. Limitations of TeleMental Health Therapy Services While TeleMental health offers several advantages such as convenience and flexibility. It is an alternative form of therapy or adjunct to therapy and thus may involve disadvantages and limitations. For example, there may 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. 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, I might not see various details such as facial expressions. Or, if audio quality is lacking, I might not hear differences in your tone of voice that I could easily pick up if you were in my office. Additionally, the therapy office decreases the likelihood of interruptions. However, there are ways to minimize interruptions and maximize privacy and effectiveness. As the therapist, I will take every precaution to ensure a technologically secure and environmentally private psychotherapy sessions. As the client, you are responsible for finding a private quiet location where the sessions may be conducted. Consider using a “do not disturb” sign/note on the door. The virtual sessions must be conducted on a wifi connection for the best connection and to minimize disruption. In Case of Technology Failure I understand that during a TeleMental health session we could encounter a technological failure. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, please call the therapist back at: 321-247-8780. Please make sure you have a phone with you, and I have that phone number. We may also reschedule if there are problems with connectivity. Structure and Cost of Sessions I offer face-to-face psychotherapy when appropriate and available. However, based on your ability to make in person sessions and my availability, I may provide virtual psychotherapy if your treatment needs determine that TeleMental health services are appropriate for you. If appropriate, you may engage in either face-to-face sessions, TeleMental health, or both. We will discuss what is best for you. Please remember that your insurance company may or may not cover therapy via phone or video. We are both responsible for understanding your mental health benefits. Please contact your insurance provider to verify coverage via TeleMental health. The structure and cost of TeleMental health sessions are exactly the same as face-to-face sessions described in my general “Client Contact and Insurance Information” form. Texting and emails (other than just setting up appointments) are billed at my hourly rate for the time I spend reading and responding. For private pay clients, I 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 I may charge your card without you
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being physically present. Your credit card will be charged at the conclusion of each TeleMental health interaction. Email: Email is not a secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to email because it is a quick way to convey information. Nonetheless, please know that it is my policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that I am required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. I 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 me via email because I may not see it in a timely matter. Instead, please see below under “Emergency Management Plan”. Please use the Patient portal on the Simple Practice to send secure communications and share documents. Social Media – Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc: If you choose to follow me on social media please do not reference our work together because it may compromise your confidentiality and blur the boundaries of our relationship. If this occurs I will block you from social media sites. Please only follow me if you are comfortable with the general public being aware of the fact that your name is attached to Gabriel Montero, MS., CCHt, LMHC, a known mental health care provider. Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have insufficient security, and I do not watch them closely. I would not want to miss an important message from you. Electronic Transfer of PHI and Credit Card Transactions: I utilize Simple Practice for billing and as the company that processes your credit card information. I may send the credit card-holder a text or an email receipt indicating that you used that credit card for my services, the date you used it, and the amount that was charged. This notification is usually set up two different ways – either upon your request at the time the card is run or automatically. Please know that it is your responsibility to know if you or the credit card holder has the automatic receipt notification set up in order to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally, please be aware that the transaction will appear on your credit card bill. You can send secure documents through the Simple Practice portal including payment information. I will use this as the primary method of communication regarding payment and other personal health information related sharing. 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 me 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.
You may alternatively follow this plan:
I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location. I understand I am solely responsible for maintaining the strict confidentiality of my user ID, password, and/or connectivity link. I shall not allow another person to use my user ID or connectivity link to access the services. I also understand that I am responsible for
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using this technology in a secure and private location so that others cannot hear my conversation. I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law. Consent to Treatment I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Gabriel Montero, MS., CCHt, LMHC to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Gabriel Montero, MS, LMHC at any time. BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. Please know that I have the utmost respect and positive regard for you and your wellbeing. I would never do or say anything intentionally to hurt you in any way, and I strongly encourage you to let me know if something I’ve done or said has upset you. I invite you to keep our communication open at all times to reduce any possible harm. Please use technology with discretion.
RELEASE OF LIABILITY TO RESUME FACE-TO-FACE SERVICES DURING COVID-19 PANDEMIC This document contains important information about our mutual decision to resume in-person services in light of the COVID-19 pandemic. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us. Decision to Meet Face-to-Face We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, I reserve the right to resume telehealth services at any time. Similarly, if you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Risks of Opting for In-Person Services You understand that by coming to the office, you are assuming the risk of exposure to COVID-19 (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service. By signing this document, you are agreeing comply with the terms of this Agreement and hereby release and forever discharge GM Counseling of 1501 West Colonial Drive, City of Orlando, State of Florida (Hereinafter the “Releasee”) including their agents, employees, successors and assigns, and their respective heirs, personal representatives, affiliates, successors and assigns, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which I now have or may hereafter have, arising out of or in any way relating to any and all injuries, sicknesses, and damages of any and every kind, to both person and property, and also any and all injuries, sicknesses, and damages that may develop in the future, as a result of or in any way relating to the following: ● The use of the property of the Releasee ● Being on the premises of the Releasee ● Conducting business for or at the premises of the Releasee Your Responsibility to Minimize Your Exposure To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families, my other staff, and other clients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement. Signing this document indicates that you understand and agree to each of the following actions: ● You will only keep your in-person appointment if you are symptom free. ● You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I won’t charge you our normal cancellation fee. ● Bathrooms are closed to the public until further notice so please make every effort to take care of your needs before coming to session. ● You will wait in your car until counselor texts you that they are ready for session. Counselor will meet you at the entrance to escort you to session. ●You will refrain touching things in the office; this includes (but is not limited to) doorknobs, light switches, pens, etc. ● You will at least wear a mask when entering and exiting the office building. ● You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or other staff]. ● You will take steps between appointments to minimize your exposure to COVID-19. ● If you have a job that exposes you to other people who are infected, you will immediately let me know. ● If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know. ● If a resident of your home tests positive for the infection, you will immediately let me know and we will then resume treatment via telehealth. I may change the above precautions if additional local, state or
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federal orders or guidelines are published. If that happens, we will talk about any necessary changes. My Commitment to Minimize Exposure My office has taken steps to reduce the risk of spreading the coronavirus within the office and we have a separate policies and procedures that all counselors in office must follow. Please let me know if you have questions about these efforts. If You or I Are Sick You understand that I am committed to keeping you, me, my colleagues and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate. If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions. Your Confidentiality in the Case of Infection If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release. Informed Consent This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together. It is understood and agreed that this Agreement is made and received in full and complete settlement and satisfaction the causes of action, claims and demands mentioned herein; that this Release contains the entire Agreement between the parties; and that the terms of this Agreement are contractual and not merely a recital. Furthermore, this Release shall be binding upon the undersigned, and his respective heirs, executors, administrators, personal representatives, successors and assigns. This Release shall be subject to and governed by the laws of the State of Florida. This Release of Liability has been read and fully understood by the undersigned.
