Welcome. To begin your therapy journey, this form will provide
you with information on my credentials, the therapy 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 #MFT.0001207
(verify here:
https://www.colorado.gov/dora/licensing/Lookup/LicenseLookup.aspx)
New Mexico Licensed Marriage & Family Therapy #CMF028781
(verify here: http://verification.rld.state.nm.us/)
Florida Licensed Marriage & Family Therapist Telehealth
Provider #TPMF62
(verify here:
https://appsmqa.dog.state.fl.us/MQASearchServices/HealthCareProviders)
Arizona Licensed Marriage & Family Therapist #15524
(verify here: https://www.azbbhe.us/node/3)
Vermont Licensed Marriage & Family Therapist #100.0134005
(verify
here: https://sos.vermont.gov/opr/find-a-professional/)
Oklahoma Licensed Marriage & Family Therapist #10049
(verify
here: https://obbhl.us.thentiacloud.net/webs/obbhl/register/#)
Iowa Licensed Marriage & Family Therapist #113317
(verify
here: https://amanda-portal.idph.state.ia.us/ibpl/portal/#/license/license-query)
Idaho Licensed Marriage & Family Therapist #8641
(verify here: https://dopl.idaho.gov)
South Carolina Licensed Marriage & Family Therapist
Telehealth Provider #TLC507
(verify here: https://llr.sc.gov/TeleHealth/Counselor.html)
Delaware Mental Health Telehealth Registration: Marriage &
Family Therapist #MI-0000049
(verify here: https://delpros.delaware.gov/oh_verifylicense)
Certifications:
Board Certified Telemental Health Provider (BC-TMH) #0878
National Association of AcuDetox Acupuncture AcuDetox Specialist
(ADS) #13797
Cornell University Family Development Credential (FDC) #006478
Experience:
Employment in the human service and behavioral health arena has
spanned over two decades, to include private and non-profit
clinic, community-based, and hospital (medical and psychiatric)
settings serving adults, adolescents and children through
individual/couple/family/group/case management/crisis assessment
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 as an individual and in
interpersonal relationships.
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.
Therapist reserves the right to terminate with client in the
event client is creating an unsafe environment for the therapist.
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. Clients must
schedule at least monthly to remain active; otherwise, the
therapist cannot guarantee space upon client's
return.
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. Also, in the event of suspected
elder or child abuse, the therapist is a mandated reporter.
Additionally, in keeping with professional standards of practice,
it is also within the realm of the therapist's role to seek
consultation or supervision from other trained/licensed
colleagues regarding the client's presenting situation or
circumstances for additional guidance when/if needed. In this
case, no personally identifying information will ever be shared;
solely pertinent facts of the client's case will be discussed.
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
clinically 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 required 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 Verizon Business
Line: 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 of 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
If the client believes it necessary to subpoena the therapist,
the client would be responsible for the therapist's fact witness
fees in the amount of $800 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 $150.00 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.
Informed Consent Regarding Form Completion Requests
If the client is requesting completion of any forms for
submission to others (e.g. FMLA), the forms will be completed at
the discretion of the therapist. Due to the increased
administrative time, form completion requests will require
payment of $50. Please submit the form completion request well in
advance of when they are needed. The therapist will attempt to
complete the forms as quickly as possible, if deemed appropriate.
An accompanying Release of Information must be completed for the
party to whom the forms are to be released, to include the
client. Payment is required prior to completion of all forms.
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, or text.
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.
Emergency Contact
If the client is ever experiencing a mental health emergency, the
client should call the National Suicide Prevention Hotline
1.800.273.8255 or 911, or go to the nearest emergency room. For
local Colorado Springs clients, it is advised that clients access
Diversus 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 goes 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.
This therapist does not provide emergency services.
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 prior to
initiating services. 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 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/
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 insurance or using
a form of Employee Assistance Program (e.g. Modern Health)
benefits for payment, by signing this document, the client is
consenting to information sharing with the insurance/third-party
biller (Headway)/EAP as required for the purposes of
authorization and billing. The client is ultimately responsible
for knowing their insurance coverage and benefits and agrees to
pay in the event that insurance denies payment both during time
of service and beyond termination. If a self-pay client wishes to
seek reimbursement from their insurance provider who is
out-of-network for this provider, the client may print a
superbill (receipt) from the portal after payment is made. If
opting for the superbill process, 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). Therapist does not guarantee reimbursement.
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 an EAP which prohibits such). If the
client is using insurance, their no-show rate will be the same as
the insurance reimbursement rate. 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 charged 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
charged 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 at minimum of 24
hours in advance of the scheduled appointment. If the appointment
is not cancelled 24 hours prior to scheduled time, the client
will be fully financially responsible for the session missed. If
using a form of EAP for session payment, a late cancel (less than
24-hours) or no-show counts toward the total sessions authorized.
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 (or insurance reimbursement rate, if applicable).
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. Three
no-shows is grounds for termination from therapy at this practice
and referrals to other community providers will be provided.
Structure of Sessions
The therapist offers counseling in person, by phone, and via
video conferencing; message-based services are also available for
already established clients, if appropriate (not covered by
insurance). Virtual 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 teletherapy, the
client can receive counseling via one medium or any combination.
For teletherapy, the client must be physically located in a state
in which the therapist is licensed to practice at the time of the
session (see Therapist Credentials section of this document for
list of active state licenses), and sessions cannot be conducted
while driving or in locations where client cannot ensure
confidentiality for themselves. If the client presents for a
virtual session and is not located as outlined above, the session
will be terminated by the therapist at the client's expense.
In-person counseling sessions are held at the therapist's office
located at 2975 Broadmoor Valley Rd., Suite 103A, Colorado
Springs, CO 80906. Please note: If coming for in-person sessions,
there is often a Therapy Dog (in training) in the office. Hazel
is a medium-sized Chinese Sharpei mix who has completed Beginner,
Intermediate, and Advanced Obedience level training, as well as
Therapy Dog training. She has yet to test and become certified,
but her continued training during office hours is in preparation
for this next step. Hazel's vaccinations are maintained current
at all times. If the client wishes for Hazel to not be present
during sessions in the office, the therapist must be advised of
such prior to any in-person sessions.
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. The client must be located in a state in which the
therapist is licensed at the time of the session. Attempting to
participate from a location where the therapist is not licensed
will result in immediate cancellation of the session, and the
client will be charged the full session fee.
Phone counseling sessions are provided via Verizon Business Line:
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 provide when prompted
during future phone sessions. This process protects the client
from another person posing as the client over the phone. The
client must be located in a state in which the therapist is
licensed at the time of the session. Attempting to participate
from a location where the therapist is not licensed will result
in cancellation of the session, and the client will be charged
the full session fee.
Limitations to Virtual Counseling (Teletherapy - video or
phone)
Virtual 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 Virtual Counseling (Teletherapy -
video or phone)
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 for Virtual
Counseling (Teletherapy - video or phone)
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 client's phone number in the portal is kept
up-to-date. 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 (Facebook:
Fulfillment Counseling & Life Coaching | Instagram:
@fulfillmentcounseling). The client will be mindful that if the
client elects to "follow" the business, this can be seen by
others. Anything the client posts 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 30 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, as well as per the Rules of the Board of Allied
Mental Health Professionals for each state in which the therapist
is licensed to practice. It is unprofessional conduct to violate
any of those rules. A copy of those rules may be obtained from
each state Board, as well as information on the process for
filing a complaint with or making consumer inquiry (see same
websites for where to verify each state license listed at
beginning of this document). 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 per the
state where the client is located, 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, ADS, to begin treatment with you.
