Repose

Studio and Wellness Offerings- Student Consent Form

Studio and Wellness Offerings from By Repose LLC and Repose Psychotherapy (Owned and Operated by Mary Breen LCSW PLLC)

I, the undersigned, understand that therapeutic movement and creative arts classes (including, but not limited to the following activities: dance movement, yoga, meditation, breathwork, and/or creative arts)  is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any active program, including By Repose LLC and Repose Psychotherapy studio classes. I recognize that it is my responsibility to notify my instructor by private chat of any serious illness or injury before every class. I will not perform any postures, positions, or movements to the extent of strain or pain. If at any time during participation in a studio class, you feel discomfort or strain, gently come out of the posture and/or stop engaging in the activity. You may reset at any time during the class. It is important in dance movement, breathwork, meditation, and yoga that you listen to your body, and respect its limits on any given day. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.

Live Online and Livestream Classes:  By participating in live online, livestream, or recorded movement, yoga, dance, meditation classes or any other wellness programs, I hereby release By Repose LLC and Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) and any instructors and/or therapists from responsibility for any injuries I may sustain as a result of participation in the classes or programs presented by the studio, including any online pre-recorded or live streamed class. I am aware that the instructor cannot see me and may not be able to offer personalized instruction, and therefore I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the classes of programs offered through the studio. I accept that neither the instructor/therapist, nor the hosting studio, is liable for any injury, or damage, to person or property, resulting from taking the class.

On-Demand Classes:  By participating in on-demand recorded movement, yoga, dance, meditation classes or any other wellness on-demand or pre-recorded programs, I hereby release By Repose LLC and Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) and any instructors and/or therapists from responsibility for any injuries I may sustain as a result of participation in the classes or programs presented by the studio, including any online pre-recorded class. I am aware that the instructor cannot see me and may not be able to offer personalized instruction, and therefore I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the classes of programs offered through the studio. I accept that neither the instructor/therapist, nor the hosting studio, is liable for any injury, or damage, to person or property, resulting from taking the class. I understand and authorize the $.01 processing fee to access on demand videos and authorize these charges.

By Repose LLC is a studio offering yoga-informed, dance movement, creative arts, and meditation group classes and wellness workshops and events. Some studio classes and offerings may be provided through Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC), but studio offerings should not be considered a substitute for the mental health services, treatment, or diagnosis provided within the scope of individual psychotherapy through Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) or any other licensed mental health provider or clinic.

Those under 18 years of age must have this form acknowledged by a parent or guardian.

Student Membership: Repose is an in-network provider for NYU Wellfleet Student Health Insurance and Aetna Preferred Plan for Columbia University students and will directly bill insurance for these drop-in group therapy class offerings. If you fail to notify us that your insurance has lapsed or is no longer active for any reason, you will be billed the full amount of the Repose Priority membership fee ($39/week). On-demand video library is available as part of your studio membership with a $0.01 processing fee not covered by insurance to access these classes.

Private Group Therapy Workshops

Please note that group therapy workshops (such as the DBT or Body Positivity groups) are not included with your student membership. These offerings may require a preliminary consultation to join and are subject to the standard copay per session as determined by your individual insurance provider. Additionally, these closed group therapy workshops have a 48 hour cancellation policy or you are responsible for the full amount of the group session. If you purchased a session package, a no-show or late cancellation will count as one used session. Thank you for respecting your provider’s time and the time that has been reserved specifically for you.

Private Individual Dance Movement, Art Therapy, and Therapeutic Yoga Sessions

Please note that individual Dance Movement, Art Therapy, and Therapeutic Yoga Sessions are not included with your student membership. These offerings may require a preliminary consultation to join and are subject to the standard copay per session as determined by your individual insurance provider. Additionally, these private, individual sessions have a 48 hour cancellation policy or you are responsible for the full amount of the session. If you purchased a session package, a no-show or late cancellation will count as one used session. Thank you for respecting your provider’s time and the time that has been reserved specifically for you.

Events

Please note that studio events are not included with your student membership unless otherwise indicated. Events may require pre registration and depending may be subject to a copay as determined by your insurance provider or may be ineligible for insurance reimbursement and therefore will be offered for a cost. Events will be subject to their own cancellation policy which, if registered, you will consent to.

Cancellation Etiquette and Policy: In order to value the time your therapist instructor has set aside for drop-in studio group therapy classes offered through your student membership, you should provide 24 hours advance notice of cancellation. For emergencies or when 24 advance notice is not possible for studio drop-in group classes, please notify your instructor through your account on www.byrepose.studio. All bookings for therapy group classes may be managed via this account.

In accordance with our cancellation policy, clients are responsible for full payment of any group therapy workshop or individual sessions not cancelled at least 48 hours in advance of a scheduled session start time. If you purchased a session package, a no-show or late cancellation will count as one used session. Thank you for respecting your provider’s time and the time that has been reserved specifically for you.

Billing: For all administrative or billing matters, please contact: billing@byrepose.com and our office will respond during regular business hours between 9am and 5pm EST Monday-Friday. Please note that any credit card charges incurred may be reflected on your credit card statement as the following entities: By Repose Psychotherapy, By Repose LLC, or Mary Breen LCSW PLLC.

Crisis Services: Please note that Repose does not provide immediate, crisis intervention services. If you are experiencing a medical or psychiatric emergency, call 911 or use a free crisis resource available 24/7.

I acknowledge and accept the above conditions. I understand that Repose (owned and operated by Mary Breen, LCSW) will bill my insurance for the therapy group classes that I have booked or for individual therapy group workshops or sessions. If I fail to notify Repose that my insurance coverage has lapsed, I understand I will be responsible for the full membership fee of $39/week. Additionally, I agree to provide 24 hours advance notice to the best of my ability for cancellations of drop-in studio group therapy classes.

I understand that Repose (owned and operated by Mary Breen, LCSW) will bill my insurance for any closed group therapy workshop and private individual sessions I enroll in and that I will be responsible for all copayments at the time of service as determined by my insurer. If I fail to notify Repose that my insurance coverage has lapsed, I understand I will be responsible for the full amount of any fees associated with the closed group workshop session and/or individual session that I have signed up for. Additionally, I accept responsibility for payment of closed group workshops, events, or individual sessions I have booked without 48 hours advance notice of cancellation.

MARY BREEN LCSW PLLC (DBA By Repose Psychotherapy)PRACTICE POLICIES

SCHEDULING

All sessions are scheduled in advance by appointment. They are generally 45 minutes long and typically occur on a weekly basis at an agreed upon time. Some sessions may be longer or more frequent depending on your needs. Requests to change the session length must be discussed in advance with your therapist in order for the time to be scheduled. Sessions typically begin and end on time for the purpose of establishing healthy therapeutic boundaries and to accommodate other clients who have scheduled appointments before or after you. If you are late for a session, you will lose some of that session time. In the event that you are out of town, sick or need additional support, phone or video chat sessions are available.

Cancellations and re-scheduled sessions must be received a minimum of 48 hours in advance of your session start time. This is necessary because a time commitment has been made to you and the session time is held exclusively for you. You will be responsible for the entire session fee if your cancellation or reschedule request is less than 48 hours from your appointment start time. Note that most insurance companies do not reimburse for missed sessions. Client requests related to scheduling, rescheduling, and cancellations will be overseen by the client coordinator and your therapist.

FEES & BILLING

The current fee-for-service for a standard 45 min session ranges from $165- $300 depending on the clinician you are working with and service requested. Full payment of the agreed upon fee-for-service during the time of your consultation or copayment is expected at the beginning of each scheduled appointment. By Repose Psychotherapy accepts payment by credit card unless previously discussed and agreed upon with your provider. Note that a $10.00 service charge will be charged for any checks returned for any reason for special handling. By Repose Psychotherapy fees are is reevaluated annually and generally increases by a nominal amount. The practice will provide you with advance notice of any increases in fees. If you are experiencing a true financial hardship or if your insurance coverage changes, we will consider working together on a sliding-scale basis or try our best to refer you to a lower-fee therapist.

• In addition to weekly appointments, the practice charges $250 per hour for other professional services you may need, though will prorate the hourly cost by quarter-hours if work is for for periods of less than one hour. Other services include the writing of reports, letters and affidavits, telephone conferences and other calls made on your behalf, consultations with other professionals with your permission, preparation of treatment records or summaries, and the time spent performing any other service you may request of the practice.

• If you become involved in legal proceedings that require the practice’s participation, you will be expected to pay in advance for all professional time, including preparation, transportation costs and travel time, as well as the cost of any legal representation the practice may incur, even if your therapist or the practice owner is called to testify by another party. Due to the complexity of legal involvement, the current fee is $400 per hour for preparation and attendance at any legal proceeding.

• If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, the practice has the option of suspending or discontinuing treatment with you and using legal means to secure payment. This may involve employing the services of a collection agency or utilizing small claims court which will require disclosure of otherwise confidential information. In most collection situations, the only information released regarding a patient's treatment is her/his/their name, the nature of the services provided, and the amount due, including any costs incurred in the process. By signing this document, you agree to bear all financial responsibility for all attorney and court costs associated with collecting an unpaid debt.

• If you have a charge from us on your card that you don’t understand, please let us know immediately by contacting us at billing@byrepose.com and we will review the charge to ensure it is legitimate and respond to you accordingly. When you have questions about a charge from us on your card, we strongly recommend that you do not formally dispute the charge through your credit card company without first bringing it to our billing team’s attention with your inquiry. Once you dispute the charge through your card issuer bank, your confidentiality is compromised and your patient privacy rights are forfeited since Repose will provide all evidence necessary to demonstrate the charge was accurate. This may include your signed cancellation policy contract and other signed practice agreements, secure message exchanges, emails, voicemails, any relevant psychotherapy notes by your therapist, or other therapists interactions with any of our team members. Additionally, we will pause treatment until this is resolved. We reserve the right to discontinue providing services due to violating practice policy by failing to pay for services rendered nor abiding by our treatment agreement guidelines.
  In summary, when you have a billing question or concern, it is best to come to us first. We will do our very best to explain all charges and if the error is on our end, we will fix it as soon as possible. Our billing office is available to help you Monday through Friday 9-5pm and may be reached at billing@byrepose.com.

• By checking the box below and submitting this form, I am agreeing to pay for each scheduled therapy session for my co-payment amount or the fee established with By Repose Psychotherapy. I understand that I am financially responsible for paying for all scheduled sessions and I am aware that insurance often does not provide reimbursement for missed appointments. I agree to provide updated credit card information to be kept on file to cover the cost of scheduled sessions that I did not show up for or that I did not cancel with at least 48 hours advance notice. I accept that any missed appointments or late cancellations will result in my credit card being charged the regular fee amount for individual psychotherapy as outlined in the Treatment Agreement Terms and Conditions. Clients who have unpaid balances of more than one session or have their credit card on file expire will be subject to paused services until updated card information is provided and the balance is paid in full.

INSURANCE REIMBURSEMENT

By Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) is a preferred provider with Wellfleet (formerly know as Consolidated Health Plans) insurance serving the New York University student body. We are also in-network with Aetna Preferred Plan serving Columbia University Students. Clients are responsible for paying the co-pays associated with this insurance plan at the beginning of each session. Per the cancellation policy and in the event that you do not provide 48 hours advance notice before canceling or no-showing to an appointment, your credit card on file will be charged the full amount of the session reimbursement amount which is currently $165.90. As previously stated in this document, most insurance companies do not reimburse for missed sessions. By signing this document, you are agreeing to full payment of any canceled or missed sessions without at least 48 hours advance notice of your appointment start time. Additionally, you are responsible for the full payment if your insurance provider denies any claim submissions.

The practice is out-of-network for all other insurances and we can provide you with the necessary statements to receive reimbursement through your out-of-network benefits. Most insurance plans offer out-of-network benefits for mental health treatment, but it is necessary that you contact your insurance company to determine exactly what coverage you are entitled to through your specific insurance policy including information about your deductible. Be advised that you (not your insurance company) are directly responsible for the full amount of all fees associated with our services at the beginning of each session and you will later be reimbursed by the insurance company for any covered expenses. Additionally, you are responsible for the full payment if your insurance provider denies any claim submissions. By signing this document, you are acknowledging that you are responsible for the full payment of your agreed upon fee-for-service.

If you wish to receive reimbursement for psychotherapy services through your insurance company, the practice is required to provide information relevant to the services provided to you. The practice will make every effort to only release the minimum information about you that is necessary for the purposes requested. Please be aware that although insurance companies claim to keep your protected health information (PHI) confidential,  the practice does not have control over how they will store or use your information.  By signing this document, you are acknowledging that we can provide the required information to your insurance carrier.

CONTACT BETWEEN SESSIONS

To reach your therapist between sessions for any non-clinical issue (scheduling, billing, etc.), please contact the client coordinator or client concierge by emailing: hello@byrepose.com or by calling (212) 920-1976. If you need to reach your therapist for any clinical reasons, it is important for you to utilize the HIPAA compliant secure messaging through Simple Practice which is accessible via your secure client portal. Your therapist checks these messages every 24-48 hours with the exception of weekends, holidays, and scheduled time off. Unless your therapist determines that it is essential to respond, your message will be addressed during your next session together. In the instance your therapist will be unavailable for an extended period of time, they will provide you with a referral another clinician within the practice in advance. Please be aware that By Repose Psychotherapy does not provide emergency services within this practice. In the event of a life or limb-threatening emergency, always call 911 or go to the nearest emergency room.

TELEPHONE ACCESSIBILITY

To make, reschedule, or cancel appointments, you may call or text the office at +1 (212) 920-1976 and leave a voicemail for the client coordinator who oversees all non-clinical client interactions. If you feel that it is necessary to contact your therapist between sessions regarding a clinical issue, you may send a message via the secure client portal. You therapist will likely not be immediately available; however, they will attempt to check messages within 1-2 business days with the exception of weekends, holidays, and scheduled vacations. Unless they determine that it is essential to return your call, clinical issues will be addressed during your next session together. When your therapist will be unavailable for an extended period of time such as during a scheduled vacation, they will offer you contact information for another therapist within the practice who you may call if necessary. By Repose Psychotherapy does not provide emergency services within this practice. If a true emergency situation arises, call 911 or go immediately to the nearest emergency room.

ELECTRONIC COMMUNICATION

Confidentiality cannot be ensured in any form of communication through electronic media, including text messages. If you prefer to communicate via email to: hello@byrepose.com or text message 212-920-1976 for issues regarding scheduling or cancellations, this is acceptable and will be responded to by the client coordinator during weekday business hours. They will attempt to return messages in a timely manner, but immediate response is unlikely. For your own protection and security, do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. As previously stated in this document, if you need to reach your therapist for any clinical reasons, please utilize safe and secure messaging through Simple Practice which is accessible via your secure client portal. Your therapist will check these messages every 24-48 hours with the exception of weekends, holidays, and scheduled time off. Unless they determine that it is essential to respond, your message will be addressed during your next session together. In the instance that your therapist will be unavailable for an extended period of time, they will provide you with a referral for another therapist within the practice in advance. By Repose Psychotherapy does not provide emergency services within this practice. If a true emergency situation arises, call 911 or go immediately to the nearest emergency room.

SOCIAL MEDIA POLICY

This office has an online social media presence for the purpose of sharing relevant information. There is no expectation that clients will follow us or read any blog/article that we may publish. If we happen to notice that you are following us, your therapist may bring it up during a session to discuss any impact that it may have on the therapeutic relationship. Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, Instagram, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and your respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when meeting with your therapist. If there is content you wish to share with your therapist from your online presence, you can explore it together during your session. Please note that By Repose does not respond to direct messages via social media platforms. If you need to reach your therapist between sessions for any reason, please do so according to the procedure previously outlined in this document.

TELECOMMUNICATIONS DEFINITION

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he/she/they would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS

If you are a minor, your parents may be legally entitled to some information about your therapy. Your therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your therapist may terminate treatment after appropriate discussion with you and a termination process if they determine that the psychotherapy is not being effectively used or if you are in default on payment. You therapist will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, Your therapist will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, your therapist must consider the professional relationship discontinued.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

 

Notice of Privacy Practices

MARY BREEN LCSW PLLC (DBA By Repose Psychotherapy)

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
   a. For my use in treating you.
   b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
   c. For my use in defending myself in legal proceedings instituted by you.
   d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
   e. Required by law and the use or disclosure is limited to the requirements of such law.
   f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
   g. Required by a coroner who is performing duties authorized by law.
   h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on June 1, 2019.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

 

Informed Consent for Psychotherapy Services

MARY BREEN LCSW PLLC (DBA By Repose Psychotherapy)

INFORMED CONSENT FOR PSYCHOTHERAPY

 

GENERAL INFORMATION

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

 

THE THERAPEUTIC PROCESS

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

CONFIDENTIALITY

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your clinical record. Your clinical record may contain information such as a diagnosis, intake information, consent to treatment, treatment plan, phone and electronic contact, and treatment notes. Treatment notes are brief summaries of our individual sessions outlining important issues, facts, or any treatment recommendations discussed. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may request in writing to examine and/or receive a copy of your clinical record. These are professional records that can be misinterpreted and/or upsetting to untrained readers. For this reason, I strongly recommend that you review them in my presence or upon your written consent, have them sent to another mental health professional to review with you.

CLINICAL CONSULTATION

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

ENCOUNTERS OUTSIDE OF THERAPY

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. If you choose to acknowledge me first, I will be more than happy to speak briefly with you; however, I feel it is most appropriate to not engage in any lengthy discussions in public or outside of the therapy office.

BY CLICKING ON THE CHECKBOX, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

MARY BREEN LCSW PLLC (DBA By Repose Psychotherapy)

CONSENT FOR TELEHEALTH

1. I understand that my health care provider has provided me with the option to engage in telehealth visits when it is not possible for me to attend an appointment in office.

2. My health care provider explained to me how the video conferencing technology that will be used to affect such a telehealth visit will not be the same as a direct client/health care provider appointment due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth visit has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by Simple Practice is another HIPAA-compliant security technology service we may use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.

• That I fully understand its contents including the risks and benefits of the procedure(s).

• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

MARY BREEN LCSW, PLLC

CANCELLATION POLICY

Consistency is an essential part of the therapeutic process. When you make an appointment, this time is reserved specifically for you and is not available to other clients. If you are unable to keep a scheduled appointment, a minimum of 48 hour advance notice from the start of your scheduled appointment time is mandatory. If you do not provide 48 hour advance notice, you will be required to pay the full amount of the session you are missing. Late cancellations and no-shows impact my schedule and my ability to help other clients who would have benefited from that session time. I respect both of our time and value my offerings which is why I strictly enforce this policy.

For this reason, you are required to keep a credit card on file. In the event that you do not provide 48 hours advance notice before canceling or no showing, I will charge your credit card on file for the full amount of the missed session. Please be advised that most insurance companies do not reimburse for missed sessions.

When 48 hours advance notice has been given and if my schedule permits, you may be offered a make-up session prior to your next regularly scheduled appointment. If a pattern emerges of you being frequently unable to keep weekly appointments, I will evaluate whether you are able to commit to therapy at this time and I reserve the option of suspending or discontinuing treatment with you.

In the rare occurrence that an emergency situation forces me to cancel your scheduled appointment, I will make every effort to provide you with as much advance notice as possible. My schedule permitting, I will reschedule our session.

If you have a charge from us on your card that you don’t understand, please let us know immediately by contacting us at billing@byrepose.com and we will review the charge to ensure it is legitimate and respond to you accordingly. 

When you have questions about a charge from us on your card, we strongly recommend that you do not formally dispute the charge through your credit card company without first bringing it to our billing team’s attention with your inquiry. Once you dispute the charge through your card issuer bank, your confidentiality is compromised and your patient privacy rights are forfeited since Repose will provide all evidence necessary to demonstrate the charge was accurate. This may include your signed cancellation policy contract and other signed practice agreements, secure message exchanges, emails, voicemails, any relevant psychotherapy notes by your therapist, or other therapists interactions with any of our team members. Additionally, we will pause treatment until this is resolved. We reserve the right to discontinue providing services due to violating practice policy by failing to pay for services rendered nor abiding by our treatment agreement guidelines. 

In summary, when you have a billing question or concern, it is best to come to us first. We will do our very best to explain all charges and if the error is on our end, we will fix it as soon as possible. Our billing office is available to help you Monday through Friday 9-5pm and may be reached at billing@byrepose.com.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Email Consent

As a multidisciplinary practice, Repose is affiliated with a wellness studio where our team provides movement and creative arts classes that complement and enhance your mental health journey. From time to time, we send our clients email updates that may include helpful tips to support your mental health, new group and studio offerings, and practice updates. By signing this form, you are consenting to receive these optional emails with the email address you have provided us to keep on file. Please note that your consent to opt into Repose emails may be revoked by you at any time. As per your rights as a client, under no circumstances will your protected health information (PHI) be used outside of your treatment at Repose nor disclosed without your explicit written permission. For more information regarding practice policies please review our Practice Policies Form.

By signing this form, I am giving my consent to receive email from Repose and understand that no information other than my name and email address will be used. I consent to receive correspondence from all Repose companies which includes the following entities: By Repose LLC and Mary Breen LCSW PLLC, D.B.A. By Repose Psychotherapy.

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