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Terms and Policy

HIPAA Notice of Privacy Practices
I. This Notice Describes How Treatment Information Pertaining to You:
A. May be used and disclosed.
B. How you can get access to this information should you elect to do so.

II. It Is Our Legal Duty to Safeguard Your "Protected Health Information" (PHI).
A. By law we are required to insure that your PHI is kept private.
B. The PHI constitutes information created or noted by us that can be used to identify you. It contains data about your past, present, or future health (including mental health) or condition, the provision of health care (including counseling) services to you, or the payment for such health care.
C. We are required to provide you with this Notice about our privacy procedures. This Notice must explain when, why, and how we would use and/or disclose your PHI.
1. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice;
2. PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party outside our practice. With some exceptions, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, we are always legally required to follow the privacy practices described in this Notice.

Please note that we reserve the right to change the terms of this Notice and our privacy policies at any time as permitted by law. Any changes will apply to PHI already on file with us. Should we make any significant changes to our policies, we will immediately change this Notice and provide a copy to you. You may also request a copy of this Notice from us at any time.

III. How We Will Use and Disclose Your PHI.
We will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of our uses and disclosures, with some examples.

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations that Do Not Require Your Prior Written Consent. We may use and disclose your PHI without your consent for the following reasons:
1. For treatment. We can use your PHI within our practice (Fulfillment Counseling & Life Coaching PLLC) to provide you with mental health treatment, including discussing or sharing your PHI with Fulfillment therapists, staff and supervisors, trainees and interns. Example: We may discuss your treatment with a supervisor or consult with another Fulfillment therapist in order to facilitate your care.
2. For health care operations. We may disclose your PHI to facilitate the efficient and correct operation of our practice. Example: We may provide your PHI to our attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws.
3. To obtain payment for treatment. We may use and disclose your PHI to bill and collect payment for the treatment and services we provided you. Example: We might send your PHI to your insurance company or health plan in order to get payment for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies or collection companies.
4. Other disclosures. Examples: Your consent is not required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your PHI.

B. Certain Other Uses and Disclosures that Do Not Require Your Consent. We may use and/or disclose your PHI without your consent or authorization for the following reasons:
1. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.
2. If disclosure is compelled or permitted by the fact that you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
3. If disclosure is mandated by the Colorado or Georgia Child Abuse and Neglect Reporting law (whichever applies given your state of residence). For example, if we have a reasonable suspicion of child abuse or neglect.
4. If disclosure is mandated by the Colorado or Georgia Elder/Dependent Adult Abuse Reporting law (whichever applies given your state of residence). For example, if we have a reasonable suspicion of elder abuse or dependent adult abuse.
5. To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public (e.g., adverse reaction to medications).
6. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: We may make a disclosure to the appropriate officials when a law requires us to report information to judicial court officials, government agencies, law enforcement personnel and/or in an administrative proceeding, of if disclosure is required by a lawful search warrant.
7. For health oversight activities. Example: We may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.
8. For specific government functions. Examples: We may disclose PHI of military personnel and veterans under certain circumstances. Also, we may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.
9. For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.
10. Appointment reminders and health related benefits or services. Examples: We may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.
11. For Workers' Compensation purposes. We may provide PHI in order to comply with Workers' Compensation laws.
12. If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.
13. If disclosure is otherwise specifically required by law. Example: If compelled by U.S. Secretary of Health and Human Services to investigate or assess our compliance with HIPAA regulations, or compelled to comply with a lawful subpoena.

C. Other Uses and Disclosures of your PHI Require Your Prior Written Authorization.

In any other situation not described in Sections IIIA and IIIB above, we will request and must obtain your written authorization before using or disclosing any of your PHI.

Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures of your PHI by us.

IV. Your Rights Pertaining to Your PHI.
These are your rights with respect to your PHI:
A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that we are legally required or permitted to make.

B. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that we correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than us. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. We are not obligated to delete any information, only add corrections or additions. Additionally, we will tell you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.

C. The Right to Get a List of the Disclosures We Have Made. You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we give you will include disclosures made from the onset of treatment unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no cost, unless you make more than one request in the same year, in which case we will charge you a reasonable sum based on a set fee for each additional request.

D. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in our possession, or to get copies of it; however, you must request it in writing. If we do not have your PHI, but we know who does, we will advise you how you can get it. You will receive a response from us within 30 days of our receiving your written request. Under certain circumstances, we may decide that we must deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have our denial reviewed. If you ask for copies of your PHI, we will charge you not more than $.99 per page. We may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

E. The Right to Choose How We Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). We are obliged to agree to your request providing that we can give you the PHI, in the format you requested, without undue inconvenience. We may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.

F. The Right to Get This Notice by Email. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.

V. How to Complain About Our Privacy Practices
If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about our privacy practices, we will take no retaliatory action against you.

VI. Person to Contact for Information About This Notice or to Complain About Our Privacy Practices.
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact the privacy officer at Fulfillment, listed below:

Dana C. Avey, M.S. M.A. DBH, LMFT, BC-TMH, ADS
2975 Broadmoor Valley Road
Suite 103A
Colorado Springs, CO 80906
VII. Effective Date of This Notice.
This notice went into effect on July 10, 2015.
( Type Full Name )
Privacy Measures for You
It is recommended that you, the client, use the same safety measures that I use for keeping your private health information (PHI) confidential.

Paper
It is recommended that you store all paper documents with your PHI in a locked cabinet.

When receiving distance counseling, it is also recommended that you:
- Conduct the sessions in private location where others cannot hear you.
- Use secure video conferencing technology https://counsol.com/site/
- If the video conferencing technology has a status bar, hide your status.
- If texting, only use a secure texting application (check settings on your cell phone for encryption options).
- Do not record any sessions.
- Password protect your computer, tablet, phone, and any other device with a password that is unique. Keep your password locked away.
- Always log out of your sessions.
- Do not have any software remember your password. Sign in every time.
- Do not share your passwords with anyone.
- Do not share your computer when you are logged onto any counseling software.
- If you wish to avoid others knowing that you are receiving counseling services, clear your browser's cache (browsing history), and on your phone, list your therapist by a name rather than as "counselor" or "therapist."
- Do not download or store information off of your client portal https://counsol.com/site/. However, if you decided to do so, only store in an encrypted file.
- Have all your devices set to time out requiring you to sign back in after a set idle time.
- Keep your computer updated.
- Use a firewall and antivirus program.
- When online, do not log in as an administrator.
- Router/Access Point
- Only use a secure network for internet access using a WAP2 security key.
- Use your own administer ID and password (not the default) for your router or access point.
- Use a custom SSID name, not the default name.
- Limit the range of your WiFi by positioning it near the center of your home.
- Notify your counselor if you suspect any breach in your security.
- For more information on securing your mobile device visit: http://www.healthit.gov/providers-professionals/how-can-you-protect-and-secure-health-information-when-using-mobile-device
( Type Full Name )
Non-Recording Agreement

Successful therapy depends on building a relationship of trust, good faith, and openness between client(s) and therapist(s).  Often, audio or video recording can inhibit candor and introspection in therapy.  Covert recording is a direct violation of trust and good faith to all the other persons in the room. 

In addition, recordings made and taken home by clients sometimes fall into unintended hands through loss, random or targeted theft, or action by police, court or governmental agency. Such loss could compromise or nullify your legal expectation of confidentiality in the extremely sensitive personal or interpersonal matters that may have been discussed.  Courts may not give your own recordings all the legal confidentiality they give to a therapist's office notes and may find them self serving. Client recordings can more easily end up becoming an issue in conflicts such as divorce, child custody, or other legal cases or be used by agencies of government.  A client who makes a recording solely for personal use or to use against a partner may later be surprised to find the recording being used against him- or herself instead.  And once an unfavorable recording exists, its deletion can become legally punishable if a subpoena is issued for it.  Additionally, most users of recording technology lack the technological tools and knowledge required to delete a recording in a way that makes it unrecoverable and un-hackable.

Factors like these undermine the therapeutic process and the building or rebuilding of trust that takes place between partners in session and between the client(s) and therapist(s).

For these reasons and others like them, Fulfillment Counseling & Life Coaching PLLC maintains a strict policy on recording.

Therefore, the client signing below agrees that:

1. Recording may only take place with the knowledge and explicit consent of ALL (not just one) clients, therapists, and other persons present during a session or other interaction, whether face-to-face or taking place by live textual, audio, or video link.

2. Consent for each recording must take the form of dated written signatures from all persons on a paper form available for that purpose, with a copy to each person recorded.  Additionally the recording itself must include the live consent of all persons present, with such consent stated at the start of the recording or when they join a session or interaction already in progress.

Fulfillment Counseling & Life Coaching PLLC will only consent to recording of a session for exceptional reasons and only after the drawbacks and risks have been discussed and the benefit clearly outweighs them.  Violation of this policy by covert recording or non-conformance with this agreement will lead to termination of therapy.

I acknowledge that I have read and understood this policy, accept it, and pledge to uphold it.

( Type Full Name )
Information, Authorization, and Consent to Treatment

Welcome. To begin your counseling journey, this form will provide you with information on my credentials, the counseling process, confidentiality, steps to take during emergencies, and other details about your treatment. At any time during your treatment, please feel free to ask any clarifying questions.


Therapist Credentials:

Licenses: 

Georgia Licensed Marriage & Family Therapist #001235                                                                          

(verify here:  http://sos.ga.gov/index.php/?section=licensing)

Colorado Licensed Marriage & Family Therapist #0001207

(verify here:  https://www.colorado.gov/dora/licensing/Lookup/LicenseLookup.aspx)

Certifications: 

Board Certified Telemental Health Provider (BC-TMH) #878

National Association of AcuDetox Acupuncture AcuDetox Specialist (ADS) #13797

Experience:

Employment in the mental health arena has spanned over a decade, to include private and non-profit clinic and hospital (medical and psychiatric) settings serving adults, adolescents and children through individual/couple/family/group modalities; consulting, supervising counseling students, and teaching at the university level.

Education:

BS in Sociology with Minor in Spanish, University of Central Oklahoma

MS in Human Services Counseling, Capella University

MA in Psychology, Marriage & Family Therapy, Northcentral University

DBH - Doctorate of Behavioral Health, Arizona State University

Scope of Practice:

Theoretical framework is that of an eclectic, systems-based, person-centered, holistic approach, using a variety of techniques from Cognitive Behavioral Therapy, Dialectical Behavior Therapy, and Solution-Focused Therapy primarily, with a belief that all individuals possess the power to change and evolve, and the role of the therapist is to assist in tapping into their own resources, abilities, and strengths in order to achieve their desired outcomes for personal growth and health toward an expressed sense of FULFILLMENT.


Client Participation:            

The client's degree of success in counseling is largely contingent upon their degree of involvement - meaning, the more the client invests in this process, the more the client is to experience perceived benefit. It is important that the client prepares prior to each session by completing any assigned therapy tasks between sessions, or "homework," and be prepared to discuss. It is also important for the client to provide feedback to the therapist if they have questions or concerns about the process. The client will not engage in the use of mind altering substances prior to sessions; if sessions are conducted in person, the client will not bring any weapons of any kind. The client's participation is entirely up to the client, so if at any time the client would like to discontinue counseling for any reason, the client will advise the therapist during a session, through secure portal email, or via phone call.  


Confidentiality and Records

The client's confidentiality is of the utmost importance to the therapist. All matters within the session will be maintained confidentially with a few exceptions. In the event the client provides details indicating an occurrence of child abuse or elder abuse, the therapist is mandated by law to report the details of this to the appropriate authorities. Likewise, in the event the client discloses information that leads the therapist to believe the client is of imminent risk of harm to themselves and/or others, the therapist is also mandated to take certain actions to ensure the safety of the client and those associated with the client - to include notifying any parties the client may be threatening to harm. Further, if the client presents meeting the criteria of gravely disabled due to mental health symptoms, the therapist is also ethically responsible for taking action to ensure the safety of the client.


In the event the client is receiving counseling services as a couple or family, no secrets will be kept from the client's partner or family if deemed therapeutically relevant for involved parties to know. If the client shares anything with the therapist that is deemed therapeutically relevant to others involved, the client will first be encouraged to disclose this themselves. The therapist will only share information with those in session when necessary for healthy therapeutic process and outcomes. 


All of the client's protected health information (PHI) is kept for a period of 10 years. It is the therapist's personal, professional, and legal obligation to keep all of the client's PHI confidential with some exceptions. The Notice of Privacy Practices form on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ (which the client is asked to sign) provides detailed information about how private information about the client's health care is protected and under what circumstances it may be shared. The following information explains how the therapist handles and stores the client's PHI while the client is receiving counseling if the client chooses any of the following counseling modalities. Although it is not guaranteed that these methods will prevent 100% of confidentiality breaches, they are designed with the intention of supporting the confidentiality of all clinical communications:

Email:

All email correspondences will be done through https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/.  https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ stores our email correspondence, but it is encrypted. 

Phone:

All phone correspondences will be done through a Comcast landline:  719-445-0840

Video Conferencing:

All video conferencing correspondences will be done through https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ which is encrypted to the federal standard.

In-person:

All session notes will be maintained through

https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ which is encrypted to the federal standard. 


In the event the therapist becomes incapacitated due to illness or injury, records may be requested by contacting Katelyn Smith, LCDC via email (katelynsmith091@yahoo.com). Katelyn Smith, LCDC has entered into an agreement to manage records as outlined through a Professional Will in the event the therapist is rendered incapable to practice.


If the client uses any other methods of electronic communication with the therapist, there is a reasonable chance that a third party may be able to intercept that communication.  However, the client has the right to consent to communication by non-secure means. By signing this document, the client understands the following:

On the https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ client portal, the client has the option to choose to have email and text reminders of appointments and billing information.

On the https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ client portal, the client has the option to sign a form titled "Consent to Unsecure Electronic Communication," and this consent would allow the therapist to transmit the client's PHI via the unsecure methods specified.

The client is not required, nor encouraged, to sign the "Consent to Unsecure Electronic Communication" agreement in order to receive treatment, and the client may terminate these consents at any time by contacting the therapist, or by changing the client's preferences on the   https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ client portal.


Client Responsibilities / Client Protection

With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may have access to any technology used by the client. Clients are encouraged to only communicate through a computer that is known to be safe and to follow the safety measures that are detailed on the "Privacy Measures" document provided on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/. The client should contact the therapist with any questions regarding the privacy measures.


Informed Consent Regarding Legal Proceedings

The client will not involve or engage the therapist in any legal issues or litigation in which the client is party to at any time either during the client's counseling or after counseling terminates. This would include any interaction with the Court system, attorneys, Guardian ad Litems, psychological evaluators, alcohol and drug evaluators, or any other contact with the legal system.  In the event that the client wishes to have a copy of the client's file for legal reasons, and the client executes a proper release, the therapist will provide the client with a treatment summary. If the client believes it necessary to subpoena the therapist, the client would be responsible for the therapist's expert witness fees in the amount of $1,500.00 for one-half (1/2) day to be paid five (5) days in advance of any court appearance or deposition. Any additional time the therapist spends over one-half (1/2) day would be billed at the rate of $375.00 per hour including travel time. Further, if the therapist is requested to have contact with the legal system on the client's behalf, the therapist will seek legal counsel for consult and the client will be responsible for any fees associated with obtaining legal counsel for the therapist. In the event the client subpoenas the therapist, the therapist may elect not to speak with the client's attorney, and a subpoena will result in the therapist withdrawing as the client's counselor.


Contacting the Therapist and Response Time

When the client needs to contact the therapist for any reason, there are effective ways to get in touch in a reasonable amount of time:

By phone: 719-445-0840. The client may leave a message on the voicemail, which is confidential.

By email, using the client portal on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/

The client will refrain from making direct contact with the therapist using any messaging systems of social media (i.e. Facebook, Instagram, Twitter, etc.).  These methods have very poor security, and the therapist is not prepared to watch them closely for important messages from clients.


The therapist may not be able to respond to client messages and calls immediately. For voicemails and other messages, the client can expect a response within 24 hours on weekdays, and 72 hours on weekends.  The therapist reserves the right to discern which messages warrant a direct reply within the designated time-frame and which messages can await feedback until the next session. There may be times when the therapist is unable to receive or respond to messages, such as when out of cellular range or out of town.


Emergency Contact

If the client is ever experiencing a mental health emergency, the client should call 911 or go to the nearest emergency room. For local Colorado Springs clients, it is advised that clients access AspenPointe's Crisis Walk In Center at 115 S. Parkside Drive, Cedar Springs Hospital at 2135 Southgate Rd., or Peak View Behavioral Health at 7353 Sisters Grove. All of these facilities operate 24/7. If the client reports somewhere due to a mental health emergency, the client is encouraged to sign releases of information once there and request staff to notify the therapist so the therapist may follow up as appropriate on their behalf. If the client needs to reach the therapist about an emergency, the best method is to message the therapist in the client portal and indicate "URGENT" in the subject line or text the therapist (706.580.7953). 


Cost of Sessions and Billing

For clients paying out of pocket for services, the cost of the sessions will be communicated clearly prior to initiation of counseling and a Self Pay Fee Agreement will be signed during the first session. The rate for service will also be stated on the client's scheduled appointment on the client portal https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/. The client is responsible for the cost of any technology at the client's location, such as a computer, phone, etc. for those scheduling teletherapy appointments. Statements are issued to the client in the portal when an appointment is scheduled. Cash and all major credit cards are acceptable for payment, and all payments are expected to be received prior to scheduled appointment. If paying by cash, the client may provide cash payment upon arrival to the appointment. Otherwise, all other payments should be made online before the session via the client portal https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ when using a card. 


The therapist reserves the right to refuse services if payment has not been received prior to start of session. If there is financial hardship, the client will discuss with the therapist in advance to services being rendered or as soon as such arises within the treatment process. For clients with Medicaid or using Employee Assistance Program (EAP) benefits for payment, by signing this document, the client is consenting to information sharing with Medicaid / EAP for the purposes of authorization and billing. If a self-pay client wishes to seek reimbursement from the client's own insurance provider (i.e. Aetna, Blue Cross Blue Shield, etc.), the client may request a Superbill from the therapist after payment is made. If opting for a Superbill, the client would then submit the Superbill to the client's insurance provider for the possibility of being reimbursed by the insurance provider (if eligible). The client is responsible for checking with the client's insurance provider regarding out-of-network mental health coverage. The client assumes all responsibility for consulting with the client's insurance provider to know what is covered versus what is not. 


By not cancelling an appointment as stated in the Cancellation Policy (see next section), the client is agreeing to the price of the session as stated on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/(unless the client is covered by a payer source that prohibits this - i.e. Medicaid, Profile EAP, EAP Works, HMSA EAP). If the client makes a payment in advance, but cancels in accordance to the Cancellation Policy, the client will be credited the amount paid for a future session. Refunds are not provided. If the client is requesting treatment documentation, the cost for documentation requested depends on the specific request. See section titled "Informed Consent Regarding Legal Proceedings" regarding fees associated with appearing in court.


The client portal https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ requires the client to have a credit card on file prior to scheduling. Unless other arrangements have been made, the client's card on file will be billed if the client has not submitted payment for the services received that day by close of business. Likewise, if the client does not cancel an appointment as outlined in the cancellation policy, the client's card will be billed by close of business the day of the scheduled session. 


Cancellation Policy

In the event the client is unable to keep an appointment, the client must cancel the appointment in the portal 24 hours in advance of the scheduled appointment. The portal will not allow you to cancel an appointment with less than 24 hours notice. If the appointment is not cancelled 24 hours prior to appointment occurring, the client will be fully financially responsible for the session missed (unless the payer source prohibits such - i.e. Medicaid, Profile EAP, EAP Works, HMSA EAP). If the client does not notify of impending late arrival and fails to show up for an appointment within the first 15 minutes of the scheduled session, it will be considered a no-show and the client's card on file will be charged accordingly for the full session rate. Insurance companies do not reimburse clients for missed sessions. Any exceptions to this policy will be based upon case-by-case emergency situations, as determined by the therapist.


Structure of Sessions

The therapist offers counseling in person, by phone, and via video conferencing.  Distance counseling, or teletherapy, is considered any of these methods other than face-to-face in person.  If the client's counseling need is appropriate for distance counseling, the client can receive counseling via one medium or any combination.

In-person counseling sessions are held at the therapist's office located at 2975 Broadmoor Valley Rd., Suite 103A, Colorado Springs, CO 80906.

Online video counseling sessions are held via https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/.  For video sessions, the client will sign onto the portal prior to the session start time. The client is responsible for initiating the connection with the therapist at the time of the client's session.

Phone counseling sessions are provided via Comcast landline: 719-445-0840. The client is responsible for initiating the call as scheduled.

If sessions are requested via phone only, the client will be required to have a brief interaction either face-to-face in person or via video conferencing in order to verify the client's identity by matching the client with the client's picture ID.  During this initial verification, the client will choose a passphrase or number which the client will use for all future phone sessions. This process protects the client from another person posing as the client over the phone.


Limitations to Distance Counseling

Distance counseling should not be viewed as a substitute for face-to-face counseling or medication by a physician.  It is an alternative form of counseling with some limitations. By signing this document the client understands that distance counseling encompasses the following possible limitations:

May lack visual and/or audio cues, which may cause misunderstanding.

May have disruptions in the service and quality of the technology used.

May not be appropriate if the client is having a crisis, experiencing acute psychosis, or is having suicidal or homicidal thoughts.

Whenever there is communication that lacks visual or audio cues, there is a risk of misunderstanding. When this happens it is important to assume that the therapist has positive regard for the client, and for the client to check out assumptions by inquiring with the therapist. This will reduce any unnecessary hardship. 


Emergency Management for Distance Counseling

In order for the therapist to properly assist the client in case of an emergency or for the client's safety, it is important that the client is aware of and commits to some critical steps. By signing this form, the client is acknowledging understanding and agreement to the following: 

The client will inform the therapist of the location in which the client will consistently be during the sessions and will inform the therapist if this location changes.

The client will identify an emergency contact person on the client information form in the portal that the therapist is allowed to contact in the event it is believed the client may be at risk. The client will verify that this emergency contact person is able and willing to go to the client's location, call 911, and/or transport the client to a hospital in the event of an emergency, if deemed necessary by the therapist.


Back Up Plan in the Event of Technology Failure

The most reliable backup for online video sessions is a phone. Therefore, it is recommended that the client always have a phone available and the therapist is made aware of the client's number. If the client gets disconnected from a video conferencing session, the client will end and restart the session. If the client is unable to reconnect within 10 minutes, the client is to call the therapist. If the client is on a phone session and the phone disconnects, the client is to call back or contact therapist via email to schedule another session. If this happens as a result of the therapist's phone or phone service in general, and the connection is unable to be re-established, the client will not be charged for the session.


Professional Relationship

The relationship between the client and the therapist must be limited to only the relationship of client and therapist.  If the client and the therapist were to interact in any other manner, the result would be a "dual relationship," which could prove to be harmful to the client in the long run. Thus, it is discouraged in the mental health profession. In addition, the therapist is required to keep the client's identity confidential, and whenever possible, the therapist will not address the client in public unless the client speaks to the therapist first. The therapist must also decline any invitation to attend gatherings with the client, the client's friends, or the client's family. This barrier also extends to social media, unless it is a professional account for Fulfillment Counseling & Life Coaching PLLC that the client wishes to follow (i.e. the business Facebook, Instagram, Twitter). The client will be mindful that if the client elects to "follow" (on Twitter, Instagram) or "like" (on Facebook) the business, this can be seen by others. Anything the client writes on these sites will become public knowledge and will not be the legal responsibility of Fulfillment Counseling & Life Coaching PLLC and/or Dr. Dana C. Avey. Lastly, when the client's therapy is completed, the therapist will not be able to be to become a social acquaintance or friend to the client due to the ethical constraints of the field in which the therapist practices. The therapist will not, at any point, accept 'Friend Requests' on social media on any of the therapist's personal accounts and the client will not request such.


Termination Policy

In the event there is not a scheduled closing session to discuss termination of the counseling relationship, and therapist has had no contact from the client within the past 60 days, the therapist will contact the client via the secure portal once to inquire if the client wishes to continue the therapeutic relationship. This message will advise of a time-frame for scheduling to remain an active client and will explain how to reach the therapist in the future for services if needed. If no appointment is scheduled within the designated time-frame as identified or agreed upon, the client's account access to the web portal will cease, and the client's chart will be closed. This action terminates the therapeutic relationship.  Any unpaid balances on the client's account will be billed to the card on file, regardless of how termination arises.   


Statement Regarding Ethics, Client Welfare & Safety

Services will be rendered in a professional manner that is consistent with the ethical standards of the American Counseling Association and the American Association of Marriage and Family Therapists. If at any time the client feels that the therapist is not performing in an ethical or professional manner, the therapist asks to be notified by the client immediately. If the client and therapist are unable to resolve the concern, the client may contact the professional licensing board that governs the therapist's profession if desired, and the therapist will make a referral to another counselor if desired.


Due to the nature of psychotherapy, the therapist cannot guarantee specific results pertaining to the client's identified therapeutic goals.  However, with the client's participation, the therapist and client will work together to achieve the best possible results for the client. At times some clients find they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as the client begins discussing certain sensitive areas of the client's life. Often, a topic is not sensitive unless it needs attention, and therefore, discovering the discomfort is actually a success. Also, the client's growth and healing during counseling may shift the dynamics of the client's relationships, and it is important for the client to be aware of this prior to starting. 


Understanding of Disclosures and Signature for Consent

As outlined in this document, the client's treatment options may include any of the following and these will be agreed upon collaboratively at the initiation of treatment: In-person, video-conferencing, and phone. The client may, at any time during the course of the client's treatment, withdraw authorization to any of these modes of treatment and/or this agreement form as a whole by simply contacting the therapist by phone or portal email. If the client has any questions pertaining to any portion of this document, the client is encouraged to ask the therapist.


Signature below is indication that you identify as the client, have read and understand the contents of this form, agree to the policies, and are authorizing the therapist, Dana C. Avey, M.S., M.A., DBH, LMFT, BC-TMH, ADS, to begin treatment with you.


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