Consent and Services Agreement
This document contains important information about our professional services and business policies. When you sign this document, it will represent an agreement between you and Lauren Trecosta. It is very important that you understand the concepts discussed below. Take your time reading it and discuss any questions you have with Lauren Trecosta.
About our Services
It’s our goal to offer a positive, empowering, and life-enriching experience for our clients. Counseling has both benefits and risks. It often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Risks may include experiencing uncomfortable feelings, such as
sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of counseling may require discussing the unpleasant aspects of your life.
During your counseling, you may receive information or reflection that will influence your decision-making. At no point are you not in the driver’s seat of your life. You are fully responsible for yourself, your decisions and any resulting consequences throughout this journey.
Counseling requires active effort on your part. In order to be most successful, you will have to work on things outside of sessions that are discussed in sessions. Further, medication may be recommended. Let me know if I can support you in your efforts to consult with a psychiatrist for prescription management. If at any point during your treatment you require psychiatric hospitalization, Lauren Trecosta will not be able to continue treatment, as she is not equipped to provide a higher level of care. She will assist you by providing referrals to other providers to ensure you get the care you need.
Confidentiality and privacy are extremely important to us. The Health Insurance Portability and Accountability Act (HIPAA), along with relevant state and local laws, strictly governs the way Lauren Trecosta handles your protected health information (PHI). As a therapist, Lauren Trecosta is in compliance with HIPAA privacy rules. Generally, there are three things we can use your protected health information for – treatment, payment, and health care operations. Our full notice of privacy practices was provided to you when you booked your appointment.
As a HIPAA covered entity, Lauren Trecosta keeps all of your PHI (including any communications you have with Lauren Trecosta) strictly confidential. However, there are exceptions to this confidence – including situations where Lauren Trecosta must disclose information pursuant to state and federal law. The following is a list of some exceptions:
- the client signs a written consent or authorization to use or disclose PHI;
- the client expresses serious intent to harm self or someone else;
- there is reasonable suspicion of abuse or neglect against a minor, elderly person, or dependent adult;
- for billing purposes;
- for supervision purposes or collegial consultation; or
- a subpoena or court order is received.
If you decide to take part in couples, family or group treatment, confidentiality rules change. For example, in compliance with applicable ethical codes, including section 2.2. and 2.3 of the AAMFT Code of Ethics, medical records or other protected health information relating to the group counseling will not be shared outside of the treatment session (even with other session participants) without a written authorization from each individual competent to execute a release, subject to any legal exceptions requiring disclosure.
Please ask your counselor.
You agree to this policy regardless of who is paying for services, and regardless of who is listed as the ‘identified patient’ for 3rd party payments.
Additionally, Lauren Trecosta has a No Secrets Policy. This means consent to treatment includes the ability for your counselor to share information with other members of the couple, family, or group participating in treatment within their clinical discretion. Lauren Trecosta will always use their best clinical judgment regarding your therapeutic treatment, however, Lauren Trecosta will not guarantee that the information provided to the counselor will be kept secret from the other members of the group counseling unit.
This does not include the release of medical records to any party within the client unit or any protected health information to a third-party without separate written authorization from every member.
You should be aware that your counselor may live and work in the community in which treatment is being provided. If ever you should see your counselor outside of a session, Lauren Trecosta’s policy is that she will not acknowledge you unless you acknowledge your counselor first. This is to protect your confidentiality.
Lastly, if you attend couple, family, or group sessions, you hereby agree not to summon Lauren Trecosta to court as a witness for any purpose or involve her in any legal proceeding that would require her to compromise the duty of confidentiality, aside from a general records request.
Lauren Trecosta is a Licensed Professional Counselor. She is licensed in Virginia.
We are required to keep appropriate records of the healthcare services that we provide to you. Your records are maintained in a secure electronic health record. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your health records with proper authorization. Please also see the reference to couples and group therapy explained above. For more information regarding how your electronic
health records are managed, please see our full notice of privacy practices.
Electronic Communication & Online Counseling
Telephone (including text), email, and videoconference are not encrypted methods of communication, and some confidentiality risk exists with their use. Our team communicates using these mediums. While we do our best to verify your email address, phone number and address at the time of intake, it is your responsibility to update your record if you would like to communicate via a different email or phone number, or if you have moved your residence.
Lauren Trecosta will abide by the laws and ethical codes of their state of licensure. While a growing base of research has shown that distance counseling services—through various electronic means—can be effective, such services are relatively new in comparison to traditional (in-person) counseling, which has a much longer track record of positive outcomes. Distance counseling may not be appropriate for some clients and for the treatment of some mental health issues.
By signing this Consent and Services Agreement, you consent to Lauren Trecosta, or someone from our team, following up with you by telephone, text or email for scheduling, billing, quality assurance, or other reasons. If you would prefer not to be contacted by email and/or text or need to update your information, you may contact me at email@example.com
Scope of Service
Lauren Trecosta will work with issues that she determines she is suited to help using distance counseling. For safety purposes and in support of getting the best treatment for the mental health issue, Lauren Trecosta does not work with people who are actively at risk of harming themselves or another or have attempted suicide in the past year. Lauren Trecosta does not offer virtual counseling or coaching to people struggling with schizophrenia, psychotic breaks, or eating disorders.
We work hard to ensure that you have a positive experience. If you have a negative experience, please tell us and we will try and make it right. If a conflict occurs, it is agreed that any disputes shall be negotiated directly between the parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences. Litigation shall be considered only if these methods are given a good faith effort.
Please provide emergency contact information on your intake form, such as a family member, mobile phone, or work phone number. These contacts may be used if your Lauren Trecosta perceives a need. Remote services are not the optimum form of services for people who are actively suicidal or have attempted suicide in the past year.
If you are actively suicidal, please contact 988 or go to your nearest emergency room.
If you, as the client, fail to attend a session within 30 days of your last counseling session, Lauren Trecosta will assume you have concluded your counseling relationship unless other arrangements have been made.
At any time after you have concluded your relationship with your counselor, you may schedule an appointment with Lauren Trecosta. You also acknowledge that Lauren Trecosta may contact you when you become an inactive client for feedback or other purposes, however you may opt out by simply responding either by verbal or written Opting Out instructions.
Lauren Trecosta does not provide distance counseling for minors under the age of 18 years old. She provides Life Coaching and psycho-education for teens 13 and older with the consent of all required legal guardians and/or parents. It is the parent or guardian’s responsibility to inform Lauren Trecosta that additional consent is required and will provide Lauren Trecosta with accurate and up-to-date information. If a custody agreement exists, you agree to provide the most recent version to your counselor. Coaching may not commence until the custody agreement and signed consent from both parents and/or legal guardians are on file.
Coordination of Care
Counseling Breakthrough believes in your integrated health care. Therefore, we ask that you provide your counselor with your Primary Care Physician’s (PCP) name and contact information shortly after your initial appointment. Your clinician will also request a Release of Information (ROI) form be completed so that they may coordinate your care as needed with your PCP, to ensure the best possible outcome.
Lauren Trecosta believes in your integrated health care. Therefore, we ask that you provide your counselor with your Primary Care Physician’s (PCP) name and contact information shortly after your initial appointment. You will be asked to sign a Release of Information (ROI) to coordinate care as needed with your PCP to ensure the best possible outcome.
Lauren Trecosta is a Licensed Professional Counselor in Virginia. She does not participate with any insurance companies. Payment is due upon booking. Upon request, you can get an invoice to submit for out-of-network benefits if you choose.
Good Faith Estimate
If you would like an estimate for services, please ask. One will be provided to you before our first scheduled session. In general, Lauren works with clients for 12 sessions and costs approximately $1,500-$1750.
Fees and Cancellation
Charges are processed at the time of booking. If you need to cancel for any reason, please do so at least 24 hours in advance. Late cancellations or no-shows will be charged a fee equal to full service. The fee is not eligible for insurance reimbursement.
All payments are made by credit card. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. Please note that we may be required to provide limited information about you and your treatment to a third party who is associated with your payment method (e.g. if you utilize a parent’s or spouse’s credit card), but that disclosure will be limited to the information
necessary to resolve the applicable billing issue.
It is Lauren Trecosta’s policy to charge for other professional services that you may require, such as producing your medical records to you or third parties, report or summary writing, or the time required to perform any other service which you may request of your counselor.
Lauren Trecosta is licensed in the Commonwealth of Virginia as a Licensed Professional Counselor. Counseling occurs in the state in which the client resides. Clients who reside outside Virginia are ineligible to receive insurance reimbursement and are engaging in Life Coaching or psycho-educational services.
ACKNOWLEDGEMENT: I have been provided a copy of Lauren Trecosta’s Notice of Privacy Practices. I have read and fully understand and agree to the terms of this Consent and Services Agreement.