This Letter of Informed Consent (the “Agreement”) is intended to provide important information regarding your therapy. The term “you”, “your” or “client” as used throughout this Agreement is defined as either (i) the adult receiving services, or (ii) parent/guardian as authorized representative on behalf of the minor receiving services. The term “I”, “we”, “our” or “us” as used throughout refers to CM Therapy, LLC and Caroline Miller, LPC, respectively. Please review the entire Agreement carefully and ask us any questions you may have regarding its contents.

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Your Therapist
I am a licensed professional counselor engaged in private practice providing mental health counseling services to clients directly. I am licensed both in the State of Missouri and State of California. I specialize in. In addition, we provide all mental health services performed under this Agreement through CM Therapy, LLC (“CM Therapy”). 

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Number of Visits
The number of sessions needed depends on many factors and will be discussed by your therapists. Your initial session will involve an evaluation of your needs which shall consist of an initial twenty (20) minute session. Depending on your circumstances further evaluative sessions may be required. At the conclusion on the evaluation process, the therapist will provide you with first impressions of what therapy may include and a treatment plan to follow. Therapy involves a substantial commitment of time, money and energy, so you should be cognizant about the therapist you select. Due to the varying nature and severity of problems and the individuality of each client, we are unable to predict the length of your therapy or to guarantee a specific outcome or result. If you have questions about the procedures, feel free to discuss the same with us at any time. 

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Fees
The fee for an initial evaluation session shall be $120.00, or as agreed upon between you and us prior to scheduling the initial consultation.  Fees for the sessions shall be $120 per 50-minute session. This includes all units of treatment: individuals, couples and or families. Payment shall be made via credit/debit card through the online processing system then in effect on our website. Should your credit/debit card information already be maintained in our files, you will not need to re-enter your credit/debit card information upon scheduling. Payment shall be taken upon scheduling of session, but only charged upon conclusion or termination of the session. Of course, we also accept checks made payable to CM Therapy, LLC or cash. Payment is due at the end of each session.  Additional fees shall be charged in the event of necessary legal work, hospital visits or insurance reports. If for some reason you find that you are unable to continue paying for your therapy, please let me know as soon as possible, and I will help you consider any options available to you at that time.

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Appointment Scheduling and Cancellation Policies
I understand that on occasion circumstances may arise resulting in your not being able to attend our session. Please contact us at least 48 hours before our scheduled appointment to advise us of your need to reschedule. If your notice of cancellation is provided within 48 hours, but prior to 24 hours before our scheduled appointment, you shall be charged for 50% of the session fees. Should your notice of cancellation be provided within 24 hours before the scheduled appointment, you shall be charged 100% of the session fees. We reserve the right to charge the credit/debit card on file. 

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Insurance
We are not on any insurance panels at this time, but upon your request, we can provide a superbill for you to submit to your insurance company for out of network coverage. You acknowledge that the superbill is not a guarantee of payment from your insurance company and CM Therapy has no control over any such outcome. 

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Relationship
Your relationship with the therapist is a professional and therapeutic relationship.  In order to preserve this relationship, it is a mandate that the therapist shall not have any other type of relationship with you. Personal and or business relationships undermine the effectiveness of the therapeutics relationship. Certainly, the therapist cares about helping you, however, this is precisely why the therapist cannot have a social or personal relationship with you. 

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Confidentiality
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s parent/legal guardian. 

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With the exception of the specific situations described below, you have the absolute right to the confidentiality of your therapy. This confidentiality is protected under the provisions of the federal Health Insurance Portability and Accountability Act (HIPAA). For detailed information regarding your rights regarding the protection of your Personal Health Information (“PHI”) please refer to the attached Notice of Privacy Practices (Notice of Privacy Practices), which reports when PHI may be used for treatment, payment, and health care options. By signing below you acknowledge that you have been provided with, read and understood a copy of the Notice of Privacy Practices.

 

In most situations, your therapist can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. This includes permission to inform your primary care physician and/or your psychiatrist that he/she is providing counseling services to you. It may be helpful for your therapist to confer with your medical professional with regard to your psychological treatment or to discuss any medical problems for which you are receiving treatment.  Should you wish to authorize the use of disclosure of your PHI, please review and complete the Authorization for use Or Disclosure of Protected Health Information (Authorization for use of Protected Health Information).
 

Your signature on this Agreement serves as your prior written consent for your therapist to consult with other health and mental health professionals about your case. The other professionals are also legally bound to keep the information confidential.

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Noted confidentiality exceptions include, but are not be limited to, the following:

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1. Duty To Warn And Protect: If you disclose intentions or a plan to harm another person, I am required to warn the intended victim and report this information. If you disclose intentions or a plan to harm themselves, you or the patient’s parent/legal guardian will be directed to seek emergency services in the community to prevent such danger.

2. Abuse Or Neglect: If you state or suggest that you are physically or sexually abusing or neglecting a child or vulnerable adult, or is in danger of physical or sexual abuse or neglect themselves, I am mandated to take steps to protect you, and required by Missouri law to report this information. However, the Department of Social Services will conduct the investigation and not our office. 

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Please refer to the attached Notice of Privacy Practices for more detailed information on how we protect your information, your rights and our responsibilities. 

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Minors and Confidentiality
Communications between therapists and patients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, in the exercise of my professional judgment, I may discuss the treatment progress of a minor patient with the parent or caretaker. Please discuss any questions or concerns with us regarding this issue.

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Cloud Services & File Security:   In order to provide you with maximum level of security, availability of your information, confidentiality, compliance and privacy with regard to your therapy, we store and maintain your file on the practice management software, SimplePractice, a cloud based solution, which is fully compliant with HIPAA. By signing below, you hereby consent to the use of the SimplePractice platform. We will endeavor to take all steps necessary to preserve and maintain the confidentiality of all your information and records; however, you recognize and agree that such information and records are subject to unauthorized access outside our control.

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Therapist Availability
You may leave a text, message via the SimplePractice portal or confidential voicemail for us at any time. If you would like us to return your call, please request that we call you back and be sure to leave your name and phone number(s), and we will make every effort to return your call within 24 hours. If you do not specifically request that we call you back and the nature of the call does not require your therapist to respond before our next session, please be aware that we will not return your call. For issues needing more immediate attention or emergencies, please call 911 or go to the nearest emergency room. I will inform you when I will be away from the office. In most cases, I will provide you at least two weeks’ notice, except in cases of an emergency, illness or unforeseen event requiring me to be absent. In the event that I am away from the office, I will provide you contact information of a colleague who is on-call for me should you need immediate assistance during my absence.

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Litigation
Due to the nature of the therapeutic process, it often involves making a full disclosure on subjects, which may be of a confidential nature. In the event of legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), you agree that neither you (the client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding. Should my appearance be required, you agree that my rate for all activities relating to the legal proceeding, including, but not limited to, preparation for court and review of records and or notes, travel time, as well as, any and all time spent in court, shall be at the rate of $500.00 per hour. 

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Therapist Communications
We may need to communicate with you by telephone, including, voicemail, text, email, mail, or other means of messaging and communications.  You hereby expressly consent that we have permission to contact you through any and all forms or medium of communication which you provide to us within the contact form or throughout any time during your engagement with us.  Please be sure to inform us within the client Intake Form [insert link to Intake Form] if you do not wish to be contacted at a particular time or place, or by a particular means. You represent and expressly agree that the “emergency contact” provided below has been notified regarding such designation and that the designated individual has fully consented to our office contacting them via telephone, text, email and or voicemail as required and as determined by our office. 

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Sensitive, clinical information is to be discussed over the phone or in- person or via videoconferencing as deemed appropriate by the therapist. For appropriate e-mail or text communication, therapist will respond to your e-mail or text within 24 hours. Potential risks of using electronic communication may include, but are not limited to; inadvertent sending of an e-mail or text containing confidential information to the wrong recipient, theft or loss of the computer, laptop or mobile device storing confidential information, and interception by an unauthorized third party through an unsecured network. E-mail messages may contain viruses or other defects and it is your responsibility to ensure that it is virus-free. In addition, e-mail or text communication may become part of the clinical record. You may be charged for time the therapist spends reading and responding e-mail or text messages.

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Social Media
As your therapist, I will not communicate with/respond to/add/like or acknowledge you through any means of social media due to issues of confidentiality and therapeutic boundaries. Your therapist does not accept friend or contact requests from current or former clients on any social networking sites. At any given time, I may have a personal and/or professional presence on social media available for clients to access at their own discretion for informational and/or therapeutic purposes. Please feel free to discuss this matter with me at any time.

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Risks of Therapy
You may learn things about yourself during therapy that you do not like. In many instances, growth cannot occur unless you experience and confront issues, which may cause you to feel sadness, anxiety or pain. The success of our work together depends on the quality of the efforts on both our parts, and the realization that you are responsible for life choices and or changes that may result from therapy.  

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Patient Rights
As a patient you have numerous rights surrounding your engagement with CM Therapy. Please review these rights within the Notice of Privacy Practices.  

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Audio or Video Recordings
You shall not record any part of your sessions unless you and the therapist mutually agree in writing that the session may be recorded.  You acknowledge that we do not consent to you recording any portion of your sessions without our prior written consent. With your permission, counseling sessions may be recorded. These recordings are occasionally reviewed for supervision purposes and used to enhance my skills and your therapy experience. These recordings will be treated confidentially and erased after they are used.

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Telehealth
You agree to receive mental health services through interactive videoconferencing (link through Simple Practice) or other forms of online therapy. You understand the use of videoconferencing or online therapy is an alternative method of mental health care delivery and that the therapist will not be physically in the same room as you.  You also acknowledge that your sessions may be interrupted due to technical failures out of our control. Should your session terminate due to your connectivity issues, you shall be responsible to pay the fee for the full session. Should the session terminate due to an issue beyond our control, you shall be responsible to pay the full session provided the majority of the session was completed prior to terminated. In the event, the session was terminated due to the fault of your therapist, and we neglected to attempt to either restore the videoconferencing or reconnect via telephone, you shall not be charged for the session.  Please complete the Telehealth Agreement. [Telehealth Agreement].

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Defamation
By signing this Agreement, you agree that you will not make defamatory comments about us and your therapist to others or to post defamatory comments about your therapist on any website or social media site. In the event that defamatory remarks about your therapist are made by you, or others acting in concern with you, you further consent by signing below to allow us and your therapist to use confidential information necessary to rebut or defend against or prosecute claims for the defamation. 

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Termination of Therapy
The length of your treatment (counseling sessions) and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. When the time comes, it is a good idea to plan for your termination in collaboration with us.  We will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or your therapist determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral(s), changing your treatment plan, or terminating your therapy.

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Other Resources
We are available to share other resources with you including reading materials, service organizations, health practitioners, educational support services, etc. Please feel free to ask for these resources with the understanding that we cannot be responsible for their value or content.

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General Terms

1. Governing Law.  This Agreement shall be governed by and construed in accordance with the laws of the State of Missouri without regard to choice of laws. 

2. Venue.  Any disputes arising under this Agreement which necessitate the filing of a lawsuit must be brought within either the Circuit Court of St. Louis County, State of Missouri, or the United States District Court for the Eastern District of Missouri.

3. Executed: Upon full execution of the parties, this Agreement shall be deemed fully executed within the State of Missouri.

4. Waiver: No failure to exercise any rights or remedies available to us and no delay in exercising any such rights or remedies shall operate as a waiver of any rights which we may have pursuant to the terms of the Agreement, in law and/or at equity.

5. Attorneys’ Fees.  In the event it becomes necessary for CM Therapy to enforce any of the provisions of this Agreement, CM Therapy shall be entitled to recover from you its reasonable attorneys’ fees incurred in such enforcement regardless of whether a lawsuit is brought, as well as, court costs and expenses in the event an action is filed.

6. Entire Agreement.  This Agreement embodies the entire Agreement between CM Therapy and you, except for those items that are specifically designated herein and or incorporated herein by reference to be agreed to between the parties from time to time

 

Consent to Therapy

I, the undersigned client, does hereby seek and consent to take part in therapy by CM Therapy LLC. I understand that developing a treatment plan with CM Therapy and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I have been informed of the risks and benefits of treatment, have had my questions answered, and believe I understand the treatment that is planned. Therefore, I hereby give CM Therapy permission to begin treatment, as shown by my signature below. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by CM Therapy.  I am aware that I may stop my treatment with CM Therapy at any time. I understand that CM Therapy is not a psychiatrist and cannot recommend or prescribe medications. I understand that CM Therapy does not practice law, medicine, finance or any other profession. 

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Your signature indicates that you have read this Agreement for services carefully and understand its contents. Please ask us to address any questions or concerns that you have about this information before you sign.

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Client Name (please print): _____________________________________

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Your Signature: ______________________________

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Date: ___________________________

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Home Address: __________________________________________

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Home Phone: _________________________________

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Email: _________________________________

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Mobile: __________________________________