Informed Consent for Therapy, Programs, and Practice Policies
Effective 01/01/2024, Updated 01/01/2021, 01/01/2022, 11/28/2023
Flourish Counseling Center LLC
Address: 3720 Nottingham Drive NW Suite C, Rochester, MN 55901
Main Office: 507-993-7731
Welcome to Flourish Counseling Center LLC. This document contains important information about your therapists' and Flourish's professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). This federal law provides privacy protections and patient rightsabout using and disclosing your Protected Health Information (PHI) for treatment, payment, and healthcare operations. Although these documents are long and sometimes complex, it is essential that you understand them. When you sign this document, you are agreeing to the terms as outlined in this document.
1.0 ABOUT YOUR THERAPIST (S)
Juanita Bateman, MA, PMH-C, Clinical Trainee: Juanita completed her master's degree in counseling and psychological services at Saint Mary's University. She completed her practicum hours at Flourish Counseling. She is especially interested in working with individuals in the perinatal period and is certified as a perinatal mental health professional by Postpartum Support International. Her gentle yet practical approach is inspired by her experiences as a childbirth educator, lactation counselor, and doula. She incorporates person-centered and cognitive behavioral approaches to foster acceptance and facilitate change in her practice. She offers compassion, understanding, and a safe space to heal. Juanita believes individuals can develop insight, tools, and wisdom to navigate life experiences.
Natalee Campbell, MPS, LPCC, LADC, is a licensed professional clinical counselor licensed by the MN Board of Behavioral Health. She received her master's degree with a focus in Integrated Behavioral Health from the University of Minnesota. Skilled in compassionate treatment of co-occurring disorders and trauma, including EMDR therapy, Natalee has extensive experience with helping individuals navigate their mental health stories.
Sarah Clarke, MA, LPCC, is a licensed professional clinical counselor licensed by the MN Board of Behavioral Health. She received her master's in clinical mental health counseling from the University of Colorado at Colorado Springs 2014. Sarah enjoys working with individuals and couples in the areas of depression, anxiety, relationships, and life transitions. She believes in using trust, empathy, and tangible life strategies to help clients find contentment and peace. Sarah's areas of expertise include trauma-informed care and helping others build healthy relationships with themselves and others.
Irene Kruger, MA, LPCC, is a licensed professional clinical counselor licensed by the MN Board of Behavioral Health. She received her master's degree in Counseling Psychology from St. Thomas University in May 2015. She is a 200-hour trained yoga instructor and has also been certified in trauma-informed yoga. She believes in transparency to build trust and in taking a client-centered approach to treatment; Irene works alongside her clients to create a plan for healing that best serves the client while remaining evidence-based and within the scope of her practice.
Allison Loftus MA, LPCC, PMH-C is a licensed professional clinical counselor approved by the MN Board of Behavioral Health. She received her master's degree in counseling and psychological services from the University of Saint Mary's in 2014. She is the founder and owner of Flourish Counseling Center, specializing in general women's mental health and maternal mental health. She is committed to creating a safe, supportive therapeutic environment where a client feels free to be herself. Allison is certified in Perinatal Mental Health through Postpartum Support International. She is an EMDRIA-trained Level 1&2 EMDR (Eye Movement Desensitization and Reprocessing) therapist and has training and experience in CBT and ACT therapy. In 2016, she completed the Circle of Security Parenting facilitator training. She is also a 200-hour trained yoga instructor. Allison believes every therapeutic relationship begins with fostering trust. From there, she designs evidence-based therapeutic interventions based on each person's goals and personality.
Lindsey Peterson, MA LICSW, is a clinical social worker licensed by the MN Board of Social Work and an approved supervisor by the MN Board of Social Work. She received a master's degree in social work from the University of North Dakota in 2015. Lindsey is committed to providing client-centered care encompassing all aspects of well-being, including physical, mental, emotional, spiritual, and relational selves. She believes in using empathy, trust, humor, and transparency to build therapeutic relationships and provide evidence-based therapeutic support. Lindsey works with adults in all stages and changes in life.
Sarita Tabor-Sour, MA, LMFT, is a Marriage and Family Therapist licensed by the MN Board of Marriage and Family Therapy. She received her master's degree in marriage and family therapy from Argosy University. Sarita loves helping people figure out how to get where they want to be and improve their lives. She has an extraordinary passion for working alongside young people to navigate the difficulties of relationships, school, work, and life. Her unique therapeutic approach helps people from all walks of life foster a life they enjoy.
Jill Wagner, MA, LICSW, is a clinical social worker licensed by the MN Board of Social Work. She received her master's degree in social work from Saint Cloud University in 2015. Jill Wagner MSW, LICSW, is a clinical social worker licensed by the MN Board of Social Work. She received her master's degree in social work from Saint Cloud State University in 2015. She works with teenagers and adults in all stages and changes in life, particularly those struggling with depression, anxiety, grief and loss, and adjustment. Jill is dedicated to the philosophy of 'meeting a client where they are at,' meaning getting to know each individual's personality, needs, and goals to assist each person in working towards the life they want to lead. Jill is committed to providing evidenced-based therapeutic support in a respectful and individualized manner that considers the various aspects of well-being, including the physical, mental, emotional, spiritual, and relational selves.
Dora Von Wald, MA, LGSW, Clinical Trainee, is a graduate social worker licensed by the MN Board of Social Work. Dora received her master's degree in social work from Winona State University in 2022. She works with adults in all stages and changes in life, particularly those struggling with trauma and abuse, disordered eating, body image, self-esteem, and adjustment. Dora believes in building a trusting and safe relationship with her clients and working with them using evidenced-based therapeutic support toward the life they want to lead. Dora considers all the various aspects of human well-being, including the physical, mental, emotional, spiritual, and relational selves. Dora loves laughing, especially with her friends and family. She enjoys a well-written memoir or novel, various crafting and art mediums, making spaces around her calm, cozy, and aesthetically pleasing, and eating really good food.
1.1 Services by a Clinical Trainee: Flourish provides clinical training to therapists. Trainees may be present during group sessions and services or in individual sessions. Services directly provided by clinical trainees or providers not credentialed with your insurance company are provided under the clinical supervision of a credentialed, licensed provider. By signing this form, you consent to receiving services by unlicensed or non-credentialed providers. Unless otherwise specified, mental health services are provided by Mental Health Professionals.
2.0 RISKS AND BENEFITS OF THERAPY
The therapeutic encounter can be a life-changing experience depending on numerous factors, including the therapeutic match, the skill and experience of the therapist, and your willingness to participate in the process. Coming to appointments regularly also enhances the therapeutic process. Some benefits include greater self-understanding, increased reflective capacity, improved relationships with loved ones, and enhanced well-being. Sometimes, therapy results in changes you might not have expected or anticipated, such as a job or relationship change. Some people may find this a positive change, while others may not. Because therapy involves talking about past and present struggles and experiences, there are times when it can be a painful process. People sometimes feel worse before they begin to feel better. However, eventually, you should start to see improvement. If you are not seeing progress, you and your therapist will discuss alternative treatments or referrals to other practitioners who may help meet your needs. It is important to discuss any concerns or questions about the therapeutic process with your therapist so you can make informed decisions about your care.
The information you disclose in therapy (including your client records) is generally confidential and will not be released to any third party without your written authorization except when required or permitted by law.
3.1 Exceptions to confidentiality: Exceptions to confidentiality include, but are not limited to,
Abuse: As a mandated reporter, the law requires therapists to report child, elder, and dependent adult abuse, serious threat of violence towards a reasonably identifiable victim, and when a patient is dangerous to themself or the person or property of another to the proper authorities.
Legal: Disclosure may also be required if you are involved in a legal proceeding initiated by you or filed against you. If you place your mental status at issue in litigation, the other party may have the right to obtain the psychotherapy records and testimony by your therapist.
Couple and Family: In couple and family therapy, confidentiality and privilege do not apply between the couple or among family members since Flourish has a no-secrets policy. Records will only be released to an outside party if there is a signed authorization to do so by all adult parties who were part of the family therapy, couple therapy, or other treatment that involved more than one adult client.
Minors: If you are a minor, your parents may be legally entitled to some information about your therapy. Your therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Professional Consultation: Occasionally, your therapist may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Only medically necessary information is shared in this context.
3.2 Group Therapy Confidentiality: Confidentiality on the part of group members is not protected by the same standards as individual therapy. To preserve all group members' confidentiality, group members agree not to mention names of group members or information that would allow group members to be easily identified outside of the group and to alert the group leader of confidentiality concerns.
3.3 Health Insurance Expectations to Confidentiality: Confidential information is disclosed to your health insurance carrier to process the claims if you choose to use insurance for services. If you decide, Flourish will bill your insurance company; only the minimum necessary information will be disclosed. Flourish, and your therapist has little control over what insurance companies do with the data submitted or who has access to it once it is released.
3.4 Privacy: You may see your therapist outside of the therapy office. If this happens, your therapist will respect your right to privacy. However, if you acknowledge your therapist first, they will say "Hello."
4.0 RECORDS AND YOUR RIGHT TO REVIEW THEM
Your therapist's clinical notes are maintained on Simple Practice. The law and the profession's standards require clinical treatment records to be kept for at least seven years. Unless otherwise agreed to be necessary, clinical records are retained only as long as Minnesota State law mandates. If you have concerns regarding the treatment records, please discuss them with your therapist. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when your therapist assesses that releasing such information might be harmful in any way. In such a case, your therapist will provide the records to an appropriate and legitimate mental health professional of your choice. Considering the above exclusions, if it is still appropriate, your therapist will release information to any agency/person you specify within 30 days upon your request and signed authorization. When more than one client is involved in treatment, your therapist will release records only with signed authorizations from all the adults who can legally authorize a release.
Flourish offers in-person and virtual appointments. Appointments are made by phone, email, or via the client portal.
Individual Psychotherapy: The standard meeting time for psychotherapy is 60 minutes. Please discuss alternative meeting times with your therapist.
Group Therapy: The standard meeting time for group therapy is 75 minutes.
Late Arrivals: Session length is only guaranteed if you are on time for the session.
Cancellations: Missed appointments and late cancellations (less than 48 hours) will be charged a flat rate of $75. This policy is strictly adhered to. If you must cancel for any reason (except for a true unforeseen emergency), a 48-hour notice by phone, email, or portal is required to avoid being charged a flat rate of $75 for your missed appointment.
Teletherapy is available as an option for cancellations.
5.1 Telemedicine: The State of Minnesota defines "telemedicine" as delivering health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site. Telemedicine may be provided using real-time two-way, interactive audio and visual communications to provide or support health care delivery. If you and your therapist choose to use telemedicine for some or all of your therapy, you need to understand that:
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.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
Dissemination of any identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
Telemedicine has potential risks, consequences, and benefits. Potential benefits include but are not limited to 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 many observations, information, and experiences about the client within a session or a series of sessions. Therapists may make clinical assessments, diagnoses, and interventions based not only on direct verbal or auditory communications, written reports, and third-person conversations but also on direct visual and olfactory observations, information, and experiences. When using telemedicine 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 apparent height and weight, body type, gait, and motor coordination, posture, any noteworthy mannerism or 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 needing to be made aware of what they would consider important information that you may not recognize as significant to present verbally to the therapist.
If you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that cannot be solved remotely, Flourish or your therapist may determine you need a higher level of care, and telemedicine services are not appropriate. An Emergency Contact Person (ECP) must be on file for your therapist to contact on your behalf in a life-threatening emergency only. This information is stored in your electronic medical chart.
Flourish, and your therapist reserves the right to determine if telemedicine is an appropriate and effective means for delivering the service to the enrollee and to terminate telemedicine at any time if telemedicine is determined not to be in the best interest of the enrollee. If termination occurs, in-person sessions or referrals to community providers are available to the client.
Flourish only offers telemedicine to clients who live within the State of Minnesota.
Flourish offers insurance and self-pay options to help you get the necessary care. The cost of services will vary depending on the type of service provided. Before your first session, we encourage you to contact the office administrator at 507-993-7731 or email firstname.lastname@example.org to review Flourish's billing policy and to discuss any personalized billing arrangements. Please note fees are subject to change. Changes to fees are posted in the lobby and on our website.
6.1 Self-Pay: Self-pay is one option to pay for mental health services. Insurance requires a diagnosis, access to your records, and specific regulations that may not meet your needs. Self-pay removes focus from the billable service and allows for greater flexibility to incorporate various care approaches at your request. Our self-pay rate is $135 for a 60-minute session and $65 for a group session. Payment is due at the time of service. Cash, check, or credit card accepted. If you choose self-pay, you are entitled to a Good Faith Estimate:
Under the No Surprises Act, healthcare providers must give clients or patients who do not have insurance or are not using insurance an estimate of the bill for medical items and services.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known when the estimate was created.
You can receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes (under the law/when applicable) related costs like medical tests, prescription drugs, equipment, and hospital fees.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. Federal law allows you to dispute (appeal) the bill if this happens.
You can dispute the bill if you receive at least $400 more than your Good Faith Estimate.
Make sure your healthcare provider gives you a Good Faith Estimate within the following timeframes:
If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
If the service is scheduled at least ten business days before the appointment date, no later than three business days after the date of schedule, or
If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service) by three business days after the date of the request. A new good faith estimate must be provided within the specified timeframes if the patient reschedules the requested item or service.
6.2 Insurance: Flourish will bill your insurance on your behalf if you choose to use insurance. Your insurance company may not cover the entire session fee, and you are responsible for any co-payments, deductible amounts, and any costs not covered by your insurance plan. It is your responsibility to check with your insurance company regarding coverage. Insurance coverage is subject to change, and not all insurance covers all our therapists or all services.
Flourish accepts the following insurance: Aetna, Blue Cross Blue Shield, Cigna, HealthPartners, Medica, Medicaid/Medical Assistance (MA), Mayo/Medica, Optum, Preferred One, Tricare, Ucare, United Behavioral Health (UBH, UHC)
Insurance Rates: Your session fee will vary based on the contracted rate between your insurance company and Flourish. Each insurance company contacts different rates with different area providers. Your insurance provider determines the rate. Flourish bills the following rates to your insurance:
Diagnostic Evaluation CPT code (90791): $225
Individual Psychotherapy CPT code (90837): $195
Couples/Family Psychotherapy CPT code (90846, 90847): $195
Group Psychotherapy CPT code (90853): $97.50
6.3 Authorization to Use and Disclose Medical Information: Flourish contracts with revenue cycle vendors to provide bookkeeping, send statements, and file insurance claims. Only the financial, diagnostic, and demographic information necessary to bill and collect for your services will be disclosed to these vendors. They explicitly respect your confidentiality. By signing this agreement, you authorize Flourish to use and disclose medical information as follows;
I consent that as a Flourish client, my Medical Information will be used, processed, and disclosed in accordance with US law and as outlined in Flourish's Informed Consent for Therapy, Programs, and Practice Policies. Furthermore, I authorize Flourish to use, process, or disclose my Medical Information:
To provide me with treatment and to coordinate my care;
To bill for and collect payment for services, which may include communications to my Payer(s) and Billing Addressee/Guarantor;
For healthcare operations as described in the Informed Consent for Therapy, Programs and Practice Policies;
For Flourish and my insurer(s) to share my past, current, and future health, treatment, and account records about services I have received from Flourish and other care providers as needed to manage or coordinate my care and improve the quality of that care;
To accrediting and quality organizations, regulatory agencies, and public health reporting agencies;
To participate in health record locator services/health information exchanges (HIE) that allow Flourish, my health care providers, insurers, and other third parties to electronically access and share my Medical Information via the HIE unless I opt-out. If I opt out, I can notify flourish at email@example.com or call 507-993-7731.
6.4 Credit card policy: Flourish uses a credit card payment system to charge for all personal liabilities for services rendered. All clients are required to have a personal credit card on file with Flourish. After your office visit is processed through insurance and invoiced, your credit card will be charged by Flourish for the balance due (i.e., out-of-network deductibles and co-pays) within one to two business days. By signing this Agreement, you agree to Flourish charging your credit card for all personal liabilities. If you choose not to have a credit card on file, all co-pays are due at the time of service.
6.5 Non-payment: If Flourish must return to any attorney or collection agency to enforce payment under this Agreement, you agree to pay all resulting charges incurred by Flourish, including but not limited to court costs and attorney's fees.
6.6 Other Charges: Site visits, report writing, consultation with other professionals, legal proceedings, legal consultation, release of information, and reading records for legal reasons are charged at $48.75 per 15-minute increment with your prior knowledge and written Agreement. Court testimony costs, plus travel and expenses, are billed at $62.50 per 15-minute increments. These services cannot be billed through your insurance company and are considered out of pocket. These fees will be payable upon receipt.
6.7 Service Fee: A $45 service fee is charged for declined credit cards and any checks returned for any reason for special handling.
6.8 Billing Contact Information: If you need to make other payment arrangements or have any questions about billing, please get in touch with the office administrator by phone at 507-993-7731 or email at firstname.lastname@example.org
7.0 TELEPHONE ACCESSIBILITY
Flourish does not maintain a 24-hour telephone emergency number. Our front desk staff can answer your calls Monday-Friday, 9 a.m. to 4:30 p.m. If you need to contact your therapist between sessions, please leave a message on our confidential voicemail or through your client portal. Therapists are often not immediately available but will attempt to return your call within two business days. Voicemail and emails are checked during regular business hours and days. If an emergency arises, please call 911 or go to the nearest emergency room.
8.0 SOCIAL MEDIA AND TELECOMMUNICATION
Due to your confidentiality and the importance of minimizing dual relationships, your therapist does not accept friend or contact requests from current or former clients on any social networking site (Facebook, Instagram, LinkedIn, etc). Adding clients as friends or contacts on these sites can compromise your confidentiality and privacy. It may also blur the boundaries of the therapeutic relationship. If you have questions, please bring them up with your therapist.
9.0 SOCIAL MEDIA MARKETING
Flourish maintains business marketing accounts on Facebook and Instagram. The health information contained within our posts and the resources available are provided for general information and education purposes only, and it is not intended. It shall not be understood as professional medical/psychological advice, diagnosis, or treatment or as a substitute for professional medical/psychological advice, diagnosis, or treatment. If you are a current or former client, please remember your comments or likes may jeopardize your confidentiality. Flourish cannot answer your questions about your situation on our social media account. Our social media pages are not a request for client testimonials, ratings, or endorsements. Multiple people manage this account. Comments and direct messages are moderated by staff and are not confidential.
10.0 ELECTRONIC COMMUNICATION
Flourish offers a secure HIPPA-compliant client portal through Simple Practice for electronic communications with providers. Electronic communication is for non-emergency communication. Call 911 or go to the nearest emergency room if an emergency arises.
10.1 Your therapist 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, please know you do so at your risk. Your therapist cannot guarantee immediate response and requests that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
10.2 If you communicate confidential or private information via unencrypted email, texts, fax, or phone messages, Flourish and your therapist assume you have made an informed decision and will view it as your agreement to take the risk that such communication may be intercepted.
10.3 To opt out of appointment reminders or communications from Flourish via email, texts, phone calls, and phone messages, notify the office administrator or your therapist in writing.
You can end therapy anytime for any reason. The termination process in therapy is crucial to ensure that the client feels heard, understood, and supported even as the therapeutic relationship concludes. This process often involves discussing the reasons for termination, exploring the progress made during therapy, addressing any unresolved issues, and making plans for future care if needed. In addition to accomplishing your goals, Flourish reserves the right to terminate therapy for the following reasons:
11.1 An essential aspect of therapy is your relationship with your therapist. If the relationship does not develop after a reasonable amount of time (three to four sessions), you should talk with your therapist about it, and a referral can be made.
11.2 Should you fail to schedule an appointment for four consecutive weeks, therapy is terminated unless other arrangements have been made in advance for legal and ethical reasons.
11.3 After a missed appointment, if your therapist does not receive communication from you and you do not schedule a future appointment, it is assumed you have chosen to terminate therapy.
11.4 If you have two late cancels/no-shows, your therapist will consider the therapeutic relationship ended, and all future appointments will be canceled.
11.5 If you request an appointment after termination, your therapist may no longer be available. You are welcome to wait until your therapist has an opening or referrals to other providers or resources are available upon request.
12.0 YOGA PROGRAMS
If you choose to participate in any of our yoga programs, you agree you have consulted with a medical provider and received approval regarding your ability to participate in yoga. You will follow Flourish's yoga instructor(s) instructions on where and how to perform yoga exercises. Understand that any deviation from such instruction shall be at your own risk. You agree any injuries suffered are caused in whole or in part by your failure to faithfully follow the guidance of the yoga instructor(s). Any physical impairment not fully disclosed to Flourish's yoga instructor(s) in writing shall be your sole responsibility.
Some of our therapists are yoga instructors. By registering for a yoga class, you are making an informed decision about the risks and benefits of participating in a yoga class with your therapist.
You're encouraged to discuss with your therapist any questions, concerns, or problems about the therapy you receive. You also have the right to file a complaint with the Minnesota Board of Behavioral Health at 121 East 7th Street St. Paul, MN 55101, 612-623-5522 or with the Minnesota Board of Social Work 2829 University Ave SE #340, Minneapolis, MN 55414, 612-617-2100, or with the Minnesota Board of Marriage and Family Therapy 335 Randolph Ave, St Paul, MN 55102, 612-617-2220.