Lacy's Counseling Solutions, LLC

Confidentiality & Records

Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI) or your PHI will be kept on my password protected computer in an encrypted file format. Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you direct me to tell someone else and you sign a “Release of Information” form; (2) I determine 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) I am ordered by a court of law to disclose information. In the latter case, my license does provide me 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 therapist. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say confidential. In working with couples and families, the couple as an entity and the family as an entity is my client. Please note that in couple’s counseling, I do not agree to keep secrets. Information revealed in any context may be discussed with either partner and processed therapeutically.

Consultation with other therapists:

Occasionally I seek professional supervision or consultation with another licensed therapist. I share information about my cases for the purpose of gaining further perspective and ideas for how to best serve my clients without revealing names or identity. Fellow therapists are bound by confidentiality so that any information shared does not leave the room in which it is shared and full names are not revealed.

Confidentiality Concerning Insurance:

If you use your health insurance to pay a part of my fees, insurance companies require some information about our therapy. To continue treatment, insurance companies often require a detailed treatment plan and a diagnosis. It is against the law for insurers to release information about our office visits. Although I believe that the insurance company will act legally, insurance companies do not always observe the same strict confidentiality polices that I do, nor can I control who views the information in the insurers’ office.

Divorce and Custody Cases:

I am not a custody evaluator and can not make any recommendations on custody. My professional ethics prevents me from doing both therapy and custody evaluations. I can refer you to other professionals who provide custody evaluation if needed. Due to the sensitive nature of divorce and all potential issues that may arise in such cases, I have very specific policies to which I ask that you agree before we enter a counseling relationship: (1.) If I am seeing a child whose parents are in the process of divorce or who are already divorced, I require a copy of the standing court order demonstrating the custodial rights of each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session. I will need to have contact with the parent who has legal custodial decision making for medical issues before I see the child for counseling and will need to obtain written consent for the child to participate in counseling from the legal custodian(s) and prefer to have contact with both parents prior to seeing the child. (2.) I will be available to provide an interview with a guardian ad litem (GAL) assigned to investigate the best interest of any child I am counseling upon production of court order demonstrating the GAL’s right to examine your clinical record or speak with me. Otherwise, the adult client or parents of child client will need to sign a release for me to speak with the GAL. The client will be charged a full session fee for this meeting. (3.) I will provide an identical summary of a child’s therapy progress, treatment plan information and parent recommendations to both parents who share in the legal custody of the child. (4.) Family sessions will likely be recommended and depending on the case, I may ask to see the child with each parent separately along with siblings and/or other significant family members. I ask all my clients waive right to subpoena me to court. This policy is set in order that I can preserve the integrity of my relationship with you and/or your child (ren). It is my experience that my appearance in court often damages my therapist-client relationship and it is my ethical duty to make every reasonable effort to promote the welfare, autonomy and best interests of my clients. By signing this agreement you are waiving right to have me subpoenaed and agreeing in fact not to have me or my records subpoenaed. I will be happy to provide a referral to another therapist who will be willing to appear in court if needed as an alternative if you would prefer. In the case I am subpoenaed to appear in court even with this waiver – whether I testify or not – I charge my full standard fee for Court Related work of $175/hour of my professional time. Any of my time dedicated to any court-mandated appearance including preparing documentation, discussions with lawyers and/or the guardian ad litem in connection with the court appearance and any time spent waiting at the court house in addition to time on the stand as well as any travel time will be billed at $175 per hour.

Fees, Payments, and Insurance:

My fees are $125.00 per 45-50 min session for an individual session and $150.00 per 60 min. for a couple/family session, and/or $75.00 per 90 minute group therapy session, unless otherwise negotiated by you or your insurance carrier. Preparation of Summaries of Treatment or Letters at request of client: $100.00 per item requested. 

Telephone calls that exceed 15 minutes in duration will be billed at $125.00 per 45-50 minutes. Payment for services is an important aspect of any professional relationship. You are responsible for seeing that my services are paid in full. This prevents you from having a past-due balance and keeps our therapeutic relationship free of undue financial tension. Payment for services is expected at the beginning of each session so that business can be out of the way. Occasionally, my fees may increase due to inflation and cost of living increases. If it becomes necessary to adjust my fees, I will always discuss it with you in advance.

You may use cash, personal check, Visa, American Express, MasterCard, or Discover. Cash App, Zelle, and PayPal are also accepted. If using a credit card, an additional fee of $3.00 per transaction will be charged. Please make all checks payable to Lacy’s Counseling Solutions. There is a $36 fee for any returned checks. That $36 fee is due at the time of your next session, along with the payment for that session. If I receive two (2) returned checks from you, I will require that you pay using cash or credit card from that point on.

Should your account become 60 days past due and arrangements for payment have not been agreed upon, I have the right to use legal means (collection agency or court system) to secure payment. In this event, I respect client’s confidentiality and only release a client’s name, dates and nature of services provided and the dollar amount due.

Filing Insurance:

Because I am a Licensed Professional Counselor, many insurance plans will reimburse you for part or all of the services I offer. Please call your benefit’s office to find out this information. If I am not on the panel for your insurance company I will be happy to provide a superbill for you to file with your insurance company for out of network reimbursement. If I am on your insurance panel, I ask that you sign a separate form providing permission to file your insurance claim. Please keep in mind the following: (1) I have no role in deciding what your insurance covers. (2) Please check your coverage, deductibles, payment rates, co-payments, and sessions allowed for the year.

Cancellation Policy:

In the event that you are unable to keep an 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.

In Case of an Emergency

My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I am unable to provide emergency services. As a private practitioner, I am not on call or available 24 hours a day. Often, I am with clients or away from my phone. I do not carry a pager nor am I available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. Generally, I will return phone calls within 24-48 hours. If you have a mental health emergency, I encourage you not to wait for a call back, but to do one or more of the following:

• Call 911. OR Go to the emergency room of your choice.

Professional Relationship/Dual Relationship:

Ethically, I cannot enter into personal (dual) relationships with clients outside of professional counseling services. Psychotherapy is a professional service I provide to you. Because of the nature of therapy, our relationship has to be different from most relationships. It may differ in how long it lasts or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other way, we would then have a “dual relationship.” 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 my clients the best care, my judgment needs to be purely focused on your needs.

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. 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. Occasionally, I may share some personal experiences in sessions when it may be beneficial, but our focus will be on you.

You should also know that therapists are required to keep the identity of their clients confidential. For your confidentiality, I will not address you in public unless you speak to me first. I may need to decline invitations to attend gatherings with your family or friends unless it is an important celebratory event that has been discussed in therapy. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In sum, it is my ethical duty as a 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:

I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the American Counseling Association. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I will provide you with information to contact the professional licensing board that governs my profession.

Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so. However, with your participation, we 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 my 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 I are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.

Technology 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 me that I maintain your confidentiality, respect your boundaries, and ascertain that your relationship with me remains therapeutic and professional. Therefore, I’ve developed the following policies:

Cell phones: It is important for you to know that cell phones may not be completely secure or confidential. However, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with me. Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. I realize that many people prefer to text and/or email because it is a quick way to convey information. However, please know that it is my policy to utilize these means of communication strictly for appointment confirmations and notices about running late for appointments. (nothing that could be inferred as therapy). Therefore, please do not bring up any therapeutic content via text or email to prevent compromising your confidentiality. If you do, please know that I will not respond. You also need to know that I am required to keep a summary or copy of all emails and texts as part of your clinical record that address anything related to therapy. Facebook, LinkedIn, Instagram, Pinterest, Twitter, Etc: It is my policy not to accept requests from any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality. I have a professional Facebook page. You are welcome to “follow” me on any of these professional pages where I post psychology information and therapeutic content. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to my practice. Please avoid making contact with me using social media messaging systems such as Facebook Messenger. These methods have insufficient security, and I do not watch them closely. I would not want to miss an important message from you.

Google, Bing, etc.: It is my policy not to search for my clients on Google or any other search engine. I respect your privacy and make it a policy to allow you to share information about yourself with me as you feel appropriate. If there is content on the Internet that you would like to share with me for therapeutic reasons, please print this material and bring it to your session.

Faxing/Emailing Medical Records:

If you authorize me (in writing) via a “Release of Information” form to send your medical records or any form of protected health information to another entity for any reason, I may need to fax that information to the authorized entity. It is my responsibility to let you know that fax machines may not be a secure form of transmitting information. Additionally, information that has been faxed may also remain in the hard drive of my fax machine. However, my fax machine is kept confidential and I am the only person who has access in my office. And, when I have successfully submitted your documents they are deleted from my device permanently.

Recommendations to Websites or Applications (Apps):

During the course of our treatment, I may recommend that you visit certain websites for pertinent information or self- help. I 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/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 and communicate to me if you would like this information as adjunct to your treatment or if you prefer that I do not make these recommendations.

In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Please feel free to ask questions, and know that I am open to any feelings or thoughts you have about these and other modalities of communication.

Information and Consent to TeleMental Health

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, I have completed specialized training in TeleMental Health. I have also developed several policies and protective measures to assure your PHI remains confidential. These are discussed below. record any TeleMental Health sessions.