Information about clients and their families is confidential with exception to the following:

1) Written authorization by the client and/or family (valid authorization form).
2) Therapist's duty to warn another in the case of potential suicide, homicide or threat of imminent, serious harm to another individual.
3) Therapist's duty to report suspicion of abuse or neglect of children or vulnerable adults.
4) Therapist's duty to report prenatal exposure to cocaine, heroin, phencyclidine, methamphetamine, and amphetamine or their derivatives, THC, or excessive & habitual alcohol use. (253b.02; 2007)
5) Therapist's duty to report the misconduct of mental health or health care professionals.
6) Therapist's duty to provide a spouse or parent of a deceased client access to their child or spouse's records.
7) Therapist's duty to provide parents of minor children access to their child's records. Minor clients can request, in writing, that particular information not be disclosed to parents. Such a request should be discussed with the therapist.
8) Therapist's duty to release records if subpoenaed by the courts.
9) Therapist's obligations to contracts (e.g. to employer of client, to an insurance carrier or health plan.)

Consent for Sharing of Confidential Information During Consultation

I am a Licensed Marriage and Family Therapist (LMFT) and Licensed Alcohol and Drug Counselor (LADC). I participate in regular group consultation with colleagues. The purpose of consulting with colleagues is to obtain additional insight, further therapeutic skills, and ensure the highest possible service to the people we serve. During collegial consultation we will make very effort to provide only those details necessary to gain adequate feedback.

My signature indicates I understand the above limits of confidentiality.

Consumers of marriage and family therapy services offered by marriage and family therapists licensed by the State of Minnesota have the right:

(1) to expect that a therapist has met the minimal qualifications of education, training, and experience required by state law; 

(2) to examine public records maintained by the Board of Marriage and Family Therapy that contain the credentials of a therapist; 

(3) to report complaints to the Board of Marriage and Family Therapy; 

(4) to be informed of the cost of professional services before receiving the services; 

(5) to privacy as defined and limited by rule and law; 

(6) to be free from being the object of unlawful discrimination while receiving services; 

(7) to have access to their records as provided in Minnesota Statutes, sections 144.291 to144.298, except as otherwise provided by law or prior written agreement; and 

(8) to be free from exploitation for the benefit or advantage of a therapist.

This document contains important information to help you understand our professional relationship and assist you in making an informed decision about your care. Please review the information below and discuss any questions you may have with me. When you sign this document, you will be stating that you received this information and understood it, and it will guide our work together.

PSYCHOTHERAPY SERVICES
Our first few sessions will involve an evaluation of your situation and needs, and we will discuss goals you would like to accomplish in our work together. Counseling is most successful when you are an active participant in the process and work on the things that we talk about both during and in between sessions. Depending on the issues you would like to address, there are a variety of treatment modalities that we may use.

During these first few sessions, we will both decide if I am the best person to provide the services you need. Psychotherapy can involve a significant investment of time, energy and money, so it is important that you are working with a counselor you feel comfortable with. If at any time you have questions about some aspect of our work together, please feel free to discuss them with me directly. If you decide that you do not want to continue in therapy with me, please tell me. If you want me to help you find another therapist or other appropriate resources, I would be happy to do so.

There are risks and benefits to participating in counseling. The risks may include experiencing uncomfortable feelings such as sadness, guilt, anger, anxiety or frustration when discussing aspects of your life. Benefits can include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and significant reductions in feelings of distress. It is impossible to predict or guarantee what risks or benefits you will personally experience.

ABOUT ME
I am a Licensed Alcohol and Drug Counselor (LADC) since 2006 and a Marriage and Family Therapist (LMFT) since 2012.

QUALIFICATIONS & EDUCATION
- Licensed Alcohol and Drug Counselor (MN License #302161)
- Licensed Marriage and Family Therapist (MN License #2594)
- MA in Marriage and Family Therapy from Saint Mary's University
- Certificate in Addiction Counseling from the University of Minnesota
- BA in Psychology from the University of Minnesota

SESSIONS
I typically weekly or biweekly with clients at a mutually agreed upon time, unless your treatment plan warrants additional services we are both in agreement with. If you arrive late for an appointment, we will only be able to meet for the remaining time in our scheduled session.

CANCELLATION POLICY
Your appointment time is reserved for you, and thus limits the ability for others to schedule during that time. If you need to cancel or reschedule a session, I request that you notify me at least 24 hours in advance. I charge $100 for no-shows and cancellations with less than 24 hours notice. Insurance companies do not reimburse for missed session fees.

PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records for all clients that I see. You are entitled to examine and/or receive a copy of your records, provided you request this in writing. Professional records can be misinterpreted or confusing to persons not trained in mental health, so we would need to review and discuss the contents together. If I believe that seeing your records would be harmful rather than beneficial for you, I will send them to a mental health professional of your choice.

CONTACTING ME

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

- An email messaging service is offered through my client portal, Counsol, which is a more secure means of communication. While it cannot be guaranteed that this will prevent 100% of confidentiality breaches, it is designed with the intention of supporting the confidentiality of clinical communications.

- By phone - 612-325-2919. You can leave a message on my confidential voicemail. When leaving a message, please leave your name, number, and best times to reach you, and whether or not it is okay to leave a message at the number you provided. I will not be able to respond to your messages and calls immediately. For voicemails and other messages, you can generally expect a response within 24 hours (excluding weekends and holidays).
- If you wish to communicate with me by normal email or normal text message, be aware that these messages are not secure or confidential and no personal information should be sent by these means.

My email services are through Hushmail. New client inquiries are forwarded from Voda Counseling's website, hosted through Squarespace. Alert messages from the electronic health record, Counsol, are used to communicate changes within my electronic record (i.e. changed / cancelled appointments, new forms to complete, when a new message is waiting for you, etc.)

Please do not make contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I will not respond.

Emergency Contact

If you are ever experiencing an emergency, including a mental health crisis, please call 911 or go to the nearest emergency room. You may also contact the National Suicide Prevention Hotline - 1-800-273-TALK (8255), available 24 hours a day.

Disclosure Regarding Third-Party Access to Communications

Please know that if you use electronic communications methods, such as email, texting, and online video, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.

Of special consideration are work and school email addresses. If you use your work email to communicate with me, your employer may access our email communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with. Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages, such as people in your home environment. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other. 

PROCESS FOR ADDRESSING CONCERNS
If you have questions or complaints about any aspect of treatment, I encourage you to discuss your concerns directly with me so that we can resolve it together. You may also file a complaint with my licensing board(s).

TERMINATING SERVICES
You are able to end therapy services at any time, and can have your client records shared with any providers you wish to coordinate or continue care. In the event that there is no contact with a client for 30 days, and no further appointments are scheduled, the file will be closed and therapy services will be terminated.

CONCLUSION
I reserve the right to change the policies, practices and procedures described in this document. I will notify you in writing of any significant changes. By signing the attached form you are indicating that you:
- Have received and read the information in this document,
- Have discussed the contents with me to your satisfaction, and
- Agree to abide by its terms during the course of our professional relationship.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

-       Get a copy of your paper or electronic medical record

-       Correct your paper or electronic medical record

-       Request confidential communication

-       Ask us to limit the information we share

-       Get a list of those with whom we've shared your information

-       Get a copy of this privacy notice

-       Choose someone to act for you

-       File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

-       Tell family and friends about your condition

-       Provide disaster relief

-       Provide mental health care

-       Market our services and sell your information

Our Uses and Disclosures

We may use and share your information as we:

-       Treat you

-       Run our organization

-       Bill for your services

-       Help with public health and safety issues

-       Do research

-       Comply with the law

-       Work with a medical examiner or funeral director

-       Address workers' compensation, law enforcement, and other government requests

-       Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

-       You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

-       We will provide a copy or a summary of your health information, usually within 30 days of your request.

-       If you ask to see or receive a copy of your record for purposes of reviewing current medical care, we may not charge you a fee.

-       If you request copies of your patient records of past medical care, or for certain appeals, we may charge you specified fees.

Ask us to correct your medical record

-       You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

-       We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

-       You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

-       We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

-       You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.

-       If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information. Minnesota Law requires consent for disclosure of treatment, payment, or operations information.

Get a list of those with whom we've shared information

-       You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.

-       We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

-       If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

-       We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

-       You can complain if you feel we have violated your rights by contacting us using the information on page 1.

-       You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

-       We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

-       Share information with your family, close friends, or others involved in your care

-       Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

-       Most sharing of psychotherapy notes

Our Uses and Disclosures How do we typically use or share your health information?

We typically use or share your health information in the following ways. We need your consent before we disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and we are unable to obtain your consent due to your condition or the nature of the medical emergency.

Treat you

We can use your health information and share it with other professionals who are treating you only if we have your consent. We can only release your health records to health care facilities and providers outside our network without your consent if it is an emergency and you are unable to provide consent due to the nature of the emergency. We may also share your health information with a provider in our network.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.We are required to obtain your consent before we release your health records to other providers for their own health care operations.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities only if we obtain your consent.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

-       Reporting suspected abuse, neglect, or domestic violence

-       Preventing or reducing a serious threat to anyone's health or safety

-       Reporting adverse reactions to medications

Do research

We can use or share your information for health research if you do not object.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Work with a medical examiner or funeral director

-       We can share health information with a coroner, medical examiner, or funeral director when an individual dies. We need consent to share information with a funeral director.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

-       For workers' compensation claims

-       For law enforcement purposes or with a law enforcement official with your consent, unless required by law.

-       With health oversight agencies for activities authorized by law

-       For special government functions such as military, national security, and presidential protective services with your consent, unless required by law.

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Other State Laws

In Minnesota, we need your consent before we disclose protected health information for treatment, payment, and operations purposes, unless the disclosure is to a related entity, or the disclosure is for a medical emergency and we are unable to obtain your consent.

Our Responsibilities

-       We are required by law to maintain the privacy and security of your protected health information.

-       We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

-       We must follow the duties and privacy practices described in this notice and give you a copy of it.

-       We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

-       We do not share your information for fund raising or marketing purposes.

-       We do not release substance abuse records without your written permission.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Other Instructions for Notice

-       Privacy officer: Annie Schwain, MA, LADC, LMFT, 612-325-2919, annie@vodacounseling.com

-       Effective date: October 5, 2018

-       This notice applies to Voda Counseling 7831 East Bush Lake Road, Suite 200G, Bloomington, MN 55439, 612-325-2919, www.vodacounseling.com

Fees are as follows:

$175 per 55 minute session

$260 per 80 minute session

$350 for a 2-hour initial discernment counseling session

$275 for follow up 90 minute discernment counseling sessions

$65 per 90-minute group session

The full session fee is charged for missed appointments or late cancellations (Less than 24-hour notice).

$175 per hour for other professional services you may need, billed in 15-minute increments. These services include, but are not limited to: preparation of records, report writing, telephone conversations lasting longer than 10 minutes, and attendance at meetings or at consultations with other professionals which you have authorized and requested.

PAYMENT
Payment is due at the beginning of each session unless prior arrangements have been made. Cash, check and all major credit cards are accepted. If you make a payment by check and your check does not clear due to insufficient funds or any other reason, you will be expected to pay in full for any related bank fees that are charged as a result. Payments for missed sessions are due prior to resuming services.

FINANCIAL HARDSHIP
A limited number of openings are set aside to accommodate couples and individuals at a reduced rate when they are facing serious economic hardship. I understand that if I would like discuss a reduced fee I must make arrangements in advance to do so.

INSURANCE
I do not take insurance directly. However, many PPOs and HMOs will cover all or a portion of my fee using your out-of-network benefits. You may also be able to use your HSA, flexible spending dollars, or medical savings account. If you would like to use your insurance, please contact your insurance provider and ask what coverage you have to see an "out-of-network provider." They will tell you what your coverage is; if possible, ask them to send you a copy of your coverage so that you can use this when you submit any documents to them in the future. Superbills to submit to your insurance are available in your account after each appointment.

I understand that Annie Schwain, MA, LADC, LMFT is not a provider for my insurance network and that I will need to pay out-of-pocket for services at the beginning of each session. I will receive an itemized bill that I can submit to my insurance company for reimbursement, should I choose to do so.

I have had the opportunity to review and discuss with my therapist the financial policies and expectations outline in this document, and agree to them as outlined above.

OVERVIEW

❖     You will need access to the certain technological services and tools to engage in virtual sessions

❖     Virtual sessions have both benefits and risks, which you and I will be monitoring as you proceed with your work

❖     It is possible that receiving services virtually will turn out to be inappropriate for you, and that we will have to cease virtual sessions

❖     You will need to participate in creating an appropriate space for your virtual sessions

❖     You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies

❖     I follow security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy

PREPARING FOR VIRTUAL SESSIONS

The Right Environment

PRIVATE - Sessions can cover very sensitive and private topics. Find a private space where no one can hear you.

Tip: Wearing headphones can reduce the potential for others to hear details of your session that would otherwise be projected from speakers.

QUIET - Minimize the potential for environmental noise.  Take the appropriate steps to silence electronics, pets, etc. so you are not disturbed during your online video sessions.

BRIGHT - Select a well lit area to connect to your session. The main light source should be in front of you to keep your face visible.  Keep your background space clear to reduce distraction.

The Right Tech Setup

HARDWARE -You must have a desktop/laptop computer and built-in or external speakers, microphone and webcam.  

SOFTWARE -Ensure you are using the latest version of your selected browser (Google Chrome, Safari, Firefox, etc.).  

Confirm your username and password are accurate so you can log into the secure client portal at the appropriate time.  

CONNECTION - You must be able to connect to a high speed internet connection (Minimum connection speed: 512Kbps Upstream / 2 Mbps Downstream). Prior to your session, restarting your computer is recommended to shutdown any background processes.  Confirm all other programs are closed so all bandwidth is dedicated to your session connection. Connect to your session prior to your session start time to test your internet connection and session settings.  Confirm you have given permissions to your browser to access your camera and microphone, and that you can see yourself in the preview window at the bottom left of the open session window.

Attending Your Session

Login to the secure client portal. Your upcoming session will be displayed on your Home page.  Click any of the details of your upcoming session to open the Session Details page, then click the Start Video Session button.  A new window will open and you should be taken directly to the virtual meeting room where you and your counselor will conduct your session.  A display of what your counselor sees will show in the bottom left, while the rest of the screen will fill with your counselor's camera view. Use the volume and microphone sensitivity dials to adjust sound settings as needed.  When the session is finished, close the window to end the connection. In the event that the CounSol platform is not working, a Google Meet link will be sent instead.

BENEFITS AND RISKS OF VIRTUAL SESSIONS

Receiving services virtually allows you to:

❖  Receive services at times or in places where the service may not otherwise be available.

❖  Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.

❖  Receive services when you are unable to travel to my office.

❖  The unique characteristics of virtual sessions may also help some people make improved progress on health goals that may not have been otherwise achievable without them.

Receiving services virtually has the following risks:

❖. Virtual sessions can be impacted by technical failures, may introduce risks to your privacy, and may reduce my ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:

❖  Internet connections and cloud services could cease working or become too unstable to use

❖. Cloud-based service personnel, IT assistants, and malicious actors ("hackers") may have the ability to access your private information that is transmitted or stored in the process of virtual session delivery.

❖. Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out. Interruptions may disrupt services at important moments, and I may be unable to reach you quickly or using the most effective tools. 

There may be additional benefits and risks to virtual sessions that arise from the lack of in-person contact or presence, the distance between you and I at the time of service, and the technological tools used to deliver services. I will assess these potential benefits and risks, sometimes in collaboration with you, as our relationship progresses.

Assessing Whether Virtual Sessions are a Good Fit For You

Although it is well validated by research, virtual sessions not a good fit for every person. Please talk to me if you find virtual sessions difficult or that it distracts from the services being provided. I will continuously assess if working virtually is appropriate for your case. If not, I am happy to meet with you in-person at my office.

SAFETY AND EMERGENCY PLAN

When doing virtual sessions, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with me. I require you to designate an emergency contact. In scheduling virtual sessions, you are giving consent for me to communicate with this person about your care if I suspect that there is a mental health or medical emergency.

Your Security and Privacy

Except where otherwise noted, I employ software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged. As with all things in telemental health, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications.

Recordings

Please do not record video or audio sessions without your provider's consent. Making recordings can quickly and easily compromise your privacy, and should be done so with great care. I will not record video or audio sessions without your consent.

Provider Name: Annie Schwain, MA, LADC, LMFT

License Number: 302161, 2594

Provider Address: 7831 East Bush Lake Road, Suite 200G, Bloomington, MN 55438

Provider Phone: 612-325-2919

Provider Tax ID: 46-2380908     

Provider NPI Number: 1225311632

You are entitled to receive this "Good Faith Estimate" of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided.  Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services that may be recommended during treatment to you that are not identified here.  

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.