04/12/2020
We’ve had to make additional changes due to COVID-19
Dear ReConnect Therapeutic Services, LLC community,
1. We are only offering audio, video conferencing (doxy.me, SimplePractice, Zoom) and Duo (a google app comparable to iPhone FaceTime app), until we are out of this crisis.
2. You can still make appointment online or contact Coach J at 678-540-4408 during our regular business hours.
3. Should you need to drop off document to the office please feel free to do so. We go to the office several times a week so we will receive the left documents. If you leave documents, please call the office and leave a message if Coach J is unavailable.
4. Coach J will call you at least 15 minutes before your scheduled appointment to collect your copay (if applicable) or other financial responsibilities and to schedule your next appointment (at least until our new appointment system is in place).
5. Below is a condensed version of our new Informed Consent that incorporates TeleMental Health. Please read it and respond yes to the attached. Responding yes acknowledges you receipt of document. and you agree and understand it's contents. Should you have any questions please free to contact Coach J at 678-540-4408.
6. Should the button not work for you, please send yes response to angela@reconnect-ta.net.
INFORMATION, AUTHORIZATION, & CONSENT TO TELEMENTAL HEALTH
Thank you so much for choosing the services that ReConnect Therapeutic Associates, LLC (RTA) provides. This document is designed to inform you about what you can expect from RTA regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains 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.” (Georgia Code 135-11-.01)
1. I understand that my health care provider, at RTA wish for me and/or my child to engage in TeleMental Health Therapy Sessions with Angela Richardson, LPC, or Kia Hansford, LPC, or Mary Campbell, LPC, or Coach J. Richardson, PLC.
2. I hereby authorize and voluntarily consent to the therapist at RTA and its contracted employees to provide me or my child with basic treatments and diagnostic evaluation information.
3. It has been explained to me that RTA will deliver therapeutic services in one of three methods: 1) video conferencing (doxy.me), 2) Telephone-audio, or 3) Duo-for all operating systems, and FaceTime-iPhone only) at this time. I understand these visits will not be the same as an in-person visit due to the fact we will not be in the same room. RTA is always expanding to meet the needs of her clientele therefore, other methods of delivering TeleMental Health therapy sessions will be included in our services.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that either the healthcare provider or I can select either format for the session. I further understand that me or my therapist can discontinue TeleMental Health services if it is felt that this form is not adequate or affective method for you or your child.
5. I understand that currently, during Corona Virus Crisis 2020, TeleMental Health is the only setting that RTA is offering for therapy sessions. Once our Country is no longer in this crisis, you will be afforded the choice of face-to-face verses TeleMental Health.
6. I understand that it is my 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.
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 me with that phone number, I may contact you on this line from my own landline in my office or from my cell phone, typically only regarding setting up an appointment if needed. If this is not an acceptable way to contact you, please let me know. Telephone conversations (other than just setting up appointments) are billed at my 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, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you, typically only regarding setting up an appointment if needed. Telephone conversations (other than just setting up appointments) are billed at my hourly rate. Additionally, I keep your phone number in my cell phone, but it is listed by your initials only and my phone is password protected. If this is a problem, please let me know, and we will discuss our options.
Text Messaging: We do not offer this mode of for therapeutic services.
Text messaging is not a secure means of communication and may compromise your confidentiality.
Furthermore, sometimes people misinterpret the meaning of a text message and/or the emotion behind it. Therefore, I do not utilize texting in my therapy practice, and I will not respond to a text message for your protection. If you happen to send me a text message by accident, you need to know that I am required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy.
Email: We do not offer this mode for therapeutic services.
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 Procedures."
Video Conferencing (VC):
Video Conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but we may also see each other on a screen. We utilize Doxy.Me. This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Doxy.Me is willing to attest to HIPAA compliance and assumes responsibility for keeping our VC interaction secure and confidential. If we choose to utilize this technology, I will give you detailed directions regarding how to log-in securely. I also ask that you please sign on to the platform at least five minutes prior to your session time to ensure we get started promptly. Additionally, you are responsible for initiating the connection with me at the time of your appointment.
I 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.).
I'm required to make sure that you're aware that I'm located in the Southeast and I abide by Eastern Standard Time. My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I do not carry a beeper 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. I will return phone calls within 24 hours. However, I do not return calls or emails 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, please call 911 or one of the emergency services listed below. For your safety, please do not wait for communication from me or RTA before call an emergency number. I encourage you not to wait for communication back from me, but do one or more of the following:
• Call Ridgeview Institute at 770.434.4567
• Call Peachford Hospital at 770.454.5589
• Go to the closet emergency room
Emergency Procedures Specific to TeleMental Health Services
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, I may determine that you need a higher level of care and TeleMental Health services are not appropriate. I will make referrals as the situation warrants.
• RTA requires an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please write this person's name and contact information below. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Please list your ECP here:
Name: ______________________________________________ Phone: _______________________
• Additionally, if either you, your ECP, or I determine necessary, the ECP agrees take you to a hospital.
• Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above.
• You agree to inform me of the address where you are at the beginning of every TeleMental Health session.
• You agree to inform me 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: _______________________
In Case of Technology Failure
Refer to complete Informed Consent located on SimplePractice Website – coming soon
Structure and Cost of Sessions
RTA has a standard copay of $35.00 which is flexible based on your insurance required copayment. Insurance companies have many rules and requirements specific to certain benefit plans.
Refer to complete Informed Consent located on SimplePractice Website – Coming soon
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 a $75.00 late cancellation/no show fee. Please note that insurance companies do not reimburse for missed sessions.
Limitations of TeleMental Health Therapy Services
Refer to complete Informed Consent located on SimplePractice Website – coming soon
Consent to TeleMental Health Services
Please check the TeleMental Health services you are authorizing me to utilize for your treatment or administrative purposes. Together, we 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 your treatment just by notifying me 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 my practice, and I will be utilizing that technology unless otherwise negotiated by you.
Email
Video Conferencing
Please respond yes, acknowledging receipt of Informed Consent, you agree to these policies, and you are authorizing me to utilize the TeleMental Health methods discussed. The complete Informed Consent document will be available on SimplePractice website in the near future.
Thank you so much for sticking with us. We look forward to supporting each other during these challenging times.
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