Informed Consent
Voluntary Consent To Treatment
Presenting to and participating in treatment at the office of Anaya Kellogg, LCSW is voluntarily. Treatment includes diagnostic, assessment and behavioral health care by Anaya Kellogg, LCSW when, in her professional judgment, is necessary or beneficial. Consent applies to all psychotherapy services, including psychological evaluation and psychotherapy.
Termination
Services will be terminated when it becomes apparent that the risks associated with treatment outwigh the benefits. Termination will always be discussed in advance, and every attempt will be made to collaborate on a transition or after-care plan. In rare circumstance, I may be ethically compelled to terminate our care without your agreement. You will be provided a written explaination of my rationale for termination.
Payment
Payment is due at the time of service. The psychotherapy rate is standardized and is detailed on the Good Faith Estimate provided at treatment start. Failure to make a payment for a rendered service may result in identifying informtion given to a collection agency or attorney to procure payment.
Telemedicine
I consent to participate in telemedicine health with Anaya Kellogg, LCSW, as part of my psychotherapy. I understand that telemedicine health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client physically in two different locations. The telemedicine platform used by this practice is the HIPAA compliant web-based service, Doxy.me. I understand the following with respect to telemedicine health:
1) I understand that there are risks, benefits, and consequences associated with telemedicine health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
2) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
3) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemedicine health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
4) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemedicine health services are not appropriate, and a higher level of care is required.
Cancellation
Occasionally, circumstances arise that necessitate the cancellation of an appointment. In this instance, notification must be given at least 24 hours in advance of the appointment time. Anaya Kellogg, LCSW will charge the full fee for a missed appointment or any session cancelled with less than 24 hours notice.
Recordkeeping
HIPAA-related documentation (privacy policies, authorizations, BAAs, notices) will be retained for 6 years. Individual records will be retained for at least 7 years after the last date of service. Electronic records are kept in an encrypted drive.
Confidentiality & HIPAA
HIPAA Guidelines and Privacy Practices are provide at treatment start. Confidentiality is extremely important to Anaya Kellogg, LCSW. Information revealed during treatment will be kept strictly confidential.
There are exceptions to this, however, that include the following:
1) Disclosure of an intention to inflict physical harm to self or another person;
2) Disclosure that physical or sexual abuse or serious neglect of a minor child has occurred;
3) Receipt of a signed, valid court order requesting records
Risks & Benefits
Therapy has both benefits and risks associated with it. On the beneficial side, therapy has been shown to produce lasting change and reduce overall feelings of distress. It can be helpful in resolving specific problems and can lead to improved relationships with significant others in life. There are, however, no guarantees of success. Risks include intermittent feelings of discomfort (such as sadness, guilt, anxiety, or anger) during and after some sessions as problems are addressed in treatment. During treatment, clients may be asked to recall difficult and unpleasant aspects of their personal and family history in order to understand the impact these lived experiences have on present functioning.