Darrett “D.J.” Burr, MA, LMHC, S-PSB, CCTP ABLE Life Recovery, PLLC d.b.a. ABLE Counseling Services Practice Mailing Address: 10612 SE 240th St. #6435 Kent, WA 98031 206-458-2556 / firstname.lastname@example.org /djburr.com I only provide telehealth mental health therapy services to residents of Washington and Florida. General Information: The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. About the therapist: I am a licensed mental health counselor(LMHC 60237239) in Washington and Flordia(TPMC965, as a telehealth provideer. I am a Specialist in Problematic Sexual Behavior, and a Certified Clinical Trauma Professional. I provide individual and group therapy to residents of Washington online via secure telehealth platforms. I own and operate ABLE Life Recovery, PLLC d.b.a ABLE Counseling Services, which is a virtual practice. ** Philosophy and Approach:** I believe counseling is an important part of self-development. I work from a person-centered approach, utilizing cognitive-behavioral strategies to help facilitate growth. I also work from a recovery mindset for those who want to explore 12 Step recovery. Education: I have a B.A. Human Services from Kennesaw State University in Kennesaw, GA, and an M.A. Community Counseling from Argosy University in Atlanta, GA. I am licensed to practice by the state of Washington. I abide by the Code of Ethics. To maintain my license, I am required to participate in continuing education, taking classes dealing with subjects relevant to this profession. I am licensed to practice by the state of Florida as a telehealth provider. I abide by Florida statute section 456.47(4). Fees: I charge $235 per individual session; $80 per group session (payable in full at the beginning of each month.; $300 for time-limited family counseling. Client Bill of Rights State Regulations (WAC 246-330-125) All patients have the following rights:
To be treated and cared for with dignity and respect;
To be protected from abuse1 and neglect9.
To access protective services.
To have confidentiality, privacy 7, 10, security8, spiritual care, and not restricted from communication with others.
If communication restrictions are necessary for patient care and safety, the facility must document and explain the restrictions to the patient and family.
To be informed and agree to their care. [Implied is: patient or their representative is given information about the procedure, the risks, and benefits, so that they may give informed consent.]
To be involved in all aspects of their care, including refusing care and treatment and resolving problems with care decisions.
To have family input in care decisions, in compliance with existing legal directives of the patient or existing court-issued legal orders.
To be informed of any unanticipated outcomes3. [Implied is: by your surgeon before being discharged from the facility.]
To complain4 about their care and treatment without fear of retribution or denial of care.
To have timely complaint resolution.
[Implied: state the timeframe].
To be provided with a written statement of their patient rights.
If the facility participates in any research, investigation, or clinical trials, they must not hinder a patient’s access to care if he refuses to participate.
Medicare Patient Rights (Appendix L): That are significantly different or in addition to state patient rights
Physicians must disclose financial interest or ownership. [May provide a list.]
Must provide patient or representative with written information concerning its policies on advance directives, and if requested, official State advance directive forms.
[Only substantiated allegations of abuse, neglect, etc., must be reported to the state authority or the local authority, or both]11
Be free from any act of discrimination or reprisal.
Receive care in a safe setting.
Be free from all forms of abuse or harassment.
ASC must comply with rules for privacy and security of health information (HIPAA). Washington State Department of Health
HSQA Complaint Intake P.O. Box 47857 Olympia, WA 98504-7857 Phone: 360-236-4700 Toll-Free: 800-633-6828 Fax: 360-236-2626 Email: mailto:HSQAComplaintIntake@doh.wa.gov Florida Department of Health: https://flhealthsource.gov/telehealth/ For additional information about this counselor or therapist, consult the Board’s website. ** The Therapeutic Process:** You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself. Confidentiality The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.
Consultation Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name. Communication In Public If we see each other accidentally outside of the virtual therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office. Benefits and Risks of Telepsychology Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient, can promote public health, and takes less time. Telepsychology, however, requires technical competence on both our parts to be helpful. Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example:
Risks to confidentiality. Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end, I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other devices. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
Issues related to technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
Crisis management and intervention. Usually, I will not engage in telepsychology with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telepsychology, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telepsychology work.
Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.
Electronic Communications I have decided to use Telehealth services via Simple Practice and Zoom. You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology. For communication between sessions, I only use phone calls, email communication, and secure chat via Simple Practice. This means that email exchanges and text messages with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email. Therefore, I will almost never discuss any clinical information by email or text and prefer that you do not either. Also, though I regularly check my email and messages, I may not be able to respond immediately, so these methods should not be used if there is an emergency. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call as soon as I can. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact in my absence if necessary. ** Appropriateness of Telepsychology** I will let you know if telepsychology is not the right fit for your mental health care, or if I decide that telepsychology is no longer the most appropriate form of treatment for you. We will discuss referrals to another professional in your location who can provide appropriate services. ** Emergencies and Technology** Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan outside of engaging in telepsychology services. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you complete a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, the Crisis Connections at 206-461-3222, or go to your nearest emergency room. Call me back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the telepsychology platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me on the phone number I provided you (206) 458-2556. Records The telepsychology sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our sessions, in the same way, I maintain records of in-person sessions in accordance with my policies. ** Thank you for trusting me with your mental health wellness.** D.J. Burr, MA, LMHC, S-PSB, CCTP email@example.com 206-458-2556 djburr.com
If you are in crisis, please call the Crisis Connections line at 866-427-4747. If this is a medical emergency call 911 immediately or go to the nearest hospital Emergency Room.