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)
New Mexico Licensed Marriage & Family Therapy #CMF028781
(verify here: http://verification.rld.state.nm.us/)
Florida Licensed Marriage & Family Therapist Telhealth
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)
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.
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 your 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 your 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
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 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
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 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 insurance or using
a form of Employee Assistance Program (EAP) benefits for payment,
by signing this document, the client is consenting to information
sharing with insurance /EAP for the purposes of authorization and
billing. If a self-pay client wishes to seek reimbursement a
client's 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 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. Profile 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 - e.g.
Profile 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. Three no-shows is grounds for termination from
therapy at this practice and referral to other community
providers.
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). 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. 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 trainings, as well as
Therapy Dog training. She has yet to test and become certified,
but her office hours are in preparation for this next step. Her
vaccinations are maintained current at all times.
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 (Tele-Therapy - video or
phone)
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.