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 LLC) 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 meds).
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:

Dr. Dana C. Avey, M.S. M.A. DBH LMFT CPRP CHLC 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.

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

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 LLC 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 LLC 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.

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.

My 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: 

Psychiatric Rehabilitation Commission Certified Psychiatric Rehabilitation Practitioner (CPRP) #180031

Spencer Institute Certified Holistic Life Coach (CHLC) #1899803849

Distance Credentialed Counselor (DCC) #1652

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 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 approach, using a variety of techniques from Cognitive Behavioral Therapy, Interpersonal Social Rhythm Therapy, Dialectical Behavior Therapy, and Solution-Focused Therapy primarily, with 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.

Your Participation:            

Your degree of success in counseling is largely contingent upon your degree of involvement - meaning, the more you invest in this process, the more you are to experience perceived benefit. It is important that you prepare prior to each session by completing any assigned therapy tasks between sessions, or "homework," and be prepared to discuss. Keep in mind, we have limited time together, so what you do between session matters.  Do not engage in the use of mind altering substances prior to sessions; if sessions are conducted in person, do not bring any weapons of any kind. Your participation is entirely up

to you, so if at any time you would like to discontinue counseling for any reason, please advise either during a session or via phone call.  

Confidentiality and Records

Your confidentiality is of the utmost importance to me.  Please know that all matters within the session will be maintained confidentially with a few exceptions. In the event you provide details indicating an occurrence of child abuse or elder abuse, I am mandated by law to report the details of this to the appropriate authorities.  Likewise, in the event you disclose information that leads me to believe you are of imminent risk of harm to yourself and/or others, I am also mandated to take certain actions to ensure the safety of you and those around you.  In the event you are receiving counseling services as a couple or family, please know that I will not keep secrets from your partner or family if deemed therapeutically relevant for involved parties.  If you share anything with me that is deemed therapeutically relevant to others involved, you will first be encouraged to disclose this yourself.  I will only share information with those in session when necessary for healthy therapeutic process and outcomes. 

All of your PHI, protected health information, is kept for a period of 10 years.  It is my personal, professional, and legal obligation to keep all your protected health information (PHI) confidential with some exceptions. The Notice of Privacy Practices form on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ (which you were asked to sign) provides detailed information about how private information about your health care is protected, and under what circumstances it may be shared.

The following information explains how I handle and store your PHI while you are receiving counseling if you choose 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. 

If you use any other methods of electronic communication with me, Dr. Dana C. Avey, there is a reasonable chance that a third party may be able to intercept that communication.  However, you have the right to consent to communication by non-secure means.  By signing this document, you - the client, understand the following:

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

On your https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ client portal you have the option to sign a form titled "Consent to Unsecure Electronic Communication," and this consent would allow me, Dr. Dana C. Avey, to transmit to you PHI via the unsecure methods that you specify.

You are not required, nor encouraged, to sign the "Consent to Unsecure Electronic Communication" agreement in order to receive treatment, and you may terminate these consents at any time by contacting myself, Dr. Dana C. Avey, or by changing your preferences on your https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ client portal.

Your Responsibilities / Your 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 that you use.  I encourage you to only communicate through a computer that you know is safe and to following the safety measures that are detailed on the "Privacy Measures" document provided on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/.  Please contact me with any questions that you may have on privacy measures.

Informed Consent Regarding Legal Proceedings

I understand that I will not involve or engage my therapist in any legal issues or litigation in which I am a party to at any time either during my 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 I wish to have a copy of my file, and I execute a proper release, my therapist will provide me with a copy of my record.  If I believe it necessary to subpoena my therapist, I would be responsible for his or her 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 I spend over one-half (1/2) day would be billed at the rate of $375.00 per hour including travel time.  I understand that if I subpoena my therapist, she may elect not to speak with my attorney, and a subpoena may result in my therapist withdrawing as my counselor.

Contacting Me

When you need to contact me for any reason, there are the most effective ways to get in touch in a reasonable amount of time:

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

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

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

Response Time

I may not be able to respond to your messages and calls immediately. For voicemails and other messages, you can expect a response within 24 hours on weekdays, and 72 hours on weekends.  Be aware that there may be times when I am unable to receive or respond to messages, such as when out of cellular range or out of town.

Emergency Contact

If you are ever experiencing an emergency, including a mental health crisis, please call 911 or go to your local emergency room. You may also access AspenPointe's Crisis Walk In Center at 115 S. Parkside Drive here in Colorado Springs (for those who are local). If you require an emergency room visit due to mental health crisis, please request hospital staff to notify me so I may follow up as appropriate.  If you need to reach me about an emergency, the best method is by phone 719-445-0840. If you cannot reach me by phone, please leave a voicemail.

Cost of Sessions and Billing

The cost of your sessions will be discussed and agreed upon between you and I and communicated clearly prior to initiation of counseling.  The rate for service will be stated on your scheduled appointment on your client portal https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/.  Fees are dependent upon the counseling medium used, the date and time, and any financial hardship that you may have.  You, the client, are responsible for the cost of any technology at your location, such as a computer, phone, etc. 

Statements are issued to you in the portal when you schedule a future appointment.  All payments are expected to be received prior to scheduled appointment.  If paying by cash, you may provide cash payment upon arrival for your appointment. Otherwise, all other payments should be made online before your session via the client portal https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ .

Fulfillment Counseling reserves the right to refuse services if payment has not been received prior to start of session. If there is financial hardship, please discuss in advance to services being rendered or as soon as such arises within the treatment process. For those with Medicaid or individuals using EAP benefits, by signing this document you are consenting to information sharing with Medicaid / EAP for the purposes of billing (if applicable).

Cash, PayPal and all major credit cards are acceptable for payment.  You may pay via your client portal https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ if using a card.  A receipt of payment will also be provided. If you wish to seek reimbursement for yourself from your own insurance provider (i.e. Aetna, Blue Cross Blue Shield, etc.), you may request a Superbill, in addition to the receipt provided by the portal, which you would then submit to your insurance provider to possibly be reimbursed by them (if applicable). If you intend to go this route, please check with your insurance provider regarding mental health coverage. You assume all responsibility for consulting with your insurance provider to know what is covered versus what is not. 

By not cancelling your appointment as stated in the cancellation policy, you are agreeing to the price of your session as stated on https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/(unless your insurance restricts this).  If you make a payment in advance, but cancel in accordance to the Cancellation Policy, you will be credited the amount paid for a future session.  The cost for documentation requested and appearing in court depends on the specific request. 

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

Cancellation Policy

In the event you are unable to keep an appointment, you must notify me within 24 hours in advance of the scheduled appointment with a phone call or portal email or by cancelling in the portal yourself.  If such advance notice is not received, you will be financially responsible for the session missed.  If you do not show up for an appointment, without prior notice, within the first 15 minutes of your scheduled session, it will be considered a no-show and your card on file will be charged accordingly for the full session rate.  Please note that insurance companies do not reimburse 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

I, Dr. Dana C. Avey, offer counseling in person and via video conferencing and phone.  Distance counseling is considered any of these methods other than face-to-face in the office.  If your counseling need is appropriate for distance counseling, you can either solely receive counseling via one medium or any combination of them.

In-person counseling sessions are held at my 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/.  It is recommended that you sign onto your https://fulfillmentcounselingandlifecoaching.securepatientarea.com/portal/ account at least 5 minutes prior to your session start time.  You are responsible for initiating the connection with me at the time of your session.

Phone counseling sessions are provided via Comcast landline: 719-445-0840. You are responsible for initiating the session as scheduled.

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

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, you agree that you understand that distance counseling encompasses the following:

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 you are having a crisis, experiencing acute psychosis, or are 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 your counselor has positive regard for you, and to check out your assumptions.  This will reduce any unnecessary hardship. 

Emergency Management for Distance Counseling

In order for me to properly assist you in case of an emergency or for your safety, it is important that you are aware of and commit to some critical steps.  By signing this form, you are acknowledging that you understand and agree to the following: 

You, the client, will inform me, your therapist, of the location in which you will consistently be during our sessions and will inform me if this location changes.

You, the client, will identify on your client information form, a person whom I, your therapist, am allowed to contact in the event I believe you are at risk.  You, the client, will verify that this emergency contact person is able and willing to go to your location in the event of an emergency, and if I deem necessary, call 911 and/or transport you to a hospital.

Back Up Plan in the Event of Technology Failure

The most reliable backup is a phone. Therefore, it is recommended that you always have a phone available, and that I, your therapist, am made aware of your number.  If you get disconnected from a video conferencing or chat session, end and restart the session.  If you are unable to reconnect within 10 minutes, call me.  If you are on a phone session and your phone disconnects, call me back or contact me to schedule another session.  If this happens as a result of my phone or phone service in general, and we are unable to reconnect, you will not be charged for the session.

Professional Relationship

Our relationship must also be limited to only the relationship of therapist and client.  If you and I were to interact in any other manner, you would then have a "dual relationship," which could prove to be harmful to you in the long run.  Additionally, it is unethical in the mental health profession.  I am also required to keep your identity confidential.  Therefore, I will not address you in public unless you speak to me first.  I must also decline any invitation to attend gatherings with you, your friends, or your family.  This barrier also extends to social media, unless it is a professional account for Fulfillment Counseling & Life Coaching LLC that you wish to follow (i.e. the business Facebook or Twitter).  Please be mindful that if you "follow" (on Twitter) or "like" (on Facebook) the business, this can be seen by others. Anything you write on those sites will become public knowledge and will not be the legal responsibility of Fulfillment Counseling & Life Coaching LLC and/or Dr. Dana C. Avey. Lastly, when your therapy is completed, I will not be able to be to become a social acquaintance or friend to you due to the ethical constraints of the field in which I practice.

Termination Policy

In the event that we do not have a closing session to discuss termination of the counseling relationship, and I have not heard from you within 60 days, I will extend myself to you via the secure portal once to inquire if you wish to continue the therapeutic relationship. This message will advise of a timeframe for scheduling to remain an active client and will explain how to reach me in the future if needed. If no appointment is scheduled within the designated timeframe identified or agreed upon, your account access to the web portal will cease, and your chart will be closed. This action terminates our therapeutic relationship.  Any unpaid balances on your account will be billed to your card on file, regardless of how termination arises.   

Statement Regarding Ethics, Client Welfare & Safety

My 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 you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately.  If we are unable to resolve your concern, I will provide you with information to contact the professional licensing board that governs my profession and make a referral to another counselor if desired.

Due to the nature of psychotherapy, I cannot guarantee specific results pertaining to your identified therapeutic goals.  However, with your participation, we will work to achieve the best possible results for you.  Please note, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better.  This may occur as you begin discussing certain sensitive areas of your life.  Keep in mind that a topic usually is not sensitive unless it needs attention, and therefore, discovering the discomfort is actually a success.  Also, your growth and healing during counseling may shift the dynamics of your relationships, and it is important for you to be aware of this prior to starting. 

I am looking forward to facilitating you on your journey toward healing and growth.  Your treatment options include any of the following and these will be agreed upon collaboratively at the initiation of treatment:

In-person          Video-Conferencing                 Phone

You may, at any time during the course of your treatment, withdraw your authorization to any of these modes of treatment and/or this agreement form as a whole  Simply contact me by phone or email.  If you have any questions pertaining to any portion of this document, please ask. 

Please sign your name below indicating that you have read and understand the contents of this form, you agree to the policies of your relationship with me as your therapist, and you are authorizing me to begin treatment with you.