Consent to Treatment

Limits of Confidentiality: All information that you disclose to me within our sessions is confidential and will not be revealed to anyone without your written permission (or your parents’ permission if you are under 18 years old). Disclosure may be authorized or required by law:

• • where there is reasonable suspicion of child abuse, elder abuse or otherwise vulnerable adult abuse (e.g., disabled);
  • where there is reasonable suspicion that you may present a danger of violence towards others;
  • where there is reasonable suspicion that you are likely to harm yourself unless protective measures are taken.

Disclosure may also be required pursuant a legal proceeding.

Records: Your clinical file will consist of (a) legal forms such as this document, (b) record of visits and payments, and (c) clinical (psychotherapy) notes.

Education, Training, and Experience: I have an MSW in Social Work and have a valid license to practice as a Clinical Social Worker in Arizona (Lic. No. LCSW-17211) and Missouri (Lic. No.2017038061). I am also a registered clinical supervisor in Arizona (No. 51364). While completing my MSW in Social Work, I also completed specialized training in Forgiveness Therapy, and I am one of the top graduates to have completed the APA accredited certificate program. Previous to my MSW, I earned an M.Ed. in Counseling Psychology and a B.S. in Disability Studies and have a valid certification to practice and supervise as a Rehabilitation Counselor nationwide (Cert. No. 111984). After receiving my MSW, I completed a Post-Graduate Fellowship in Psychoanalytic Thought, Post-Graduate Hypnosis Training, and an ADA Coordinator Certification (Cert. No. 66935970-4617). I have also earned the designations of Clinically Certified Domestic Violence Counselor (Cert. No. 29243), Certified Trauma Professional Level 2 (Cert. No. 578775), Certified Forensic Social Worker (Cert. No. 29243), Certified Storytelling Leader (Cert. No. cer-056c99d1-ae96-4e3b-b443-9a2bec), Certified Autism Spectrum Disorder Clinical Specialist (Cert. No. 304356). And, I am certified in Seizure First Aid (Cert. ID. nbapo4cajq). My clinical experience includes crisis intervention, hostage negotiation, evaluation and treatment of past abuse, trauma, domestic violence, intimate partner violence, sexual abuse, post-traumatic stress disorder (PTSD), psychogenic non-epileptic seizures (PNES), anger, depression, anxiety, addictions, and chronic pain; career counseling, case management, advocacy, accommodations of people who experience disabilities, blindness, limited vision, and deafblindness. My experience also includes treating medical conditions from the medical model, researching and writing policies and law, providing training and supervision for clinicians, counselors and other professionals, as well as standard of care and forensic expert related services.

Length and Success of Services: The length and success of psychological treatment depends on the motivation and aptitude of the person being treated, and so I can make no guarantees of success. I allow you to decide when to terminate the treatment.

Risk of Services: You should be aware, although I anticipate otherwise, despite treatment you may not improve at all, you may not improve as quickly as you may like, or you may start to improve only after treatment has ended. You should also be aware that treatment is intended to induce change in your life, and that when this change occurs it may disrupt your accustomed manner of living and your relationships with others. Treatment can also provoke feelings of affection for me or anger at me, and these experiences should be considered normal aspects of treatment to be discussed openly with me.

Your Rights: You may review information that I have about you at any time. You may terminate services at any time.

In all cases, professional treatment never includes sexual contact with the treatment provider.

Couples and Family Therapy: I do not provide treatment, as in psychotherapy and alcohol/substance abuse counseling, for minor children because it has been my experience that the parents also need treatment. Additionally, it’s been my experience that one person is more ready to change than another within the family system and change can begin to happen within the entire family by starting with one adult.

Nevertheless, for clients already established in individual treatment, I have occasionally conducted joint sessions with a spouse or a parent, but my role in such sessions is simply to be a facilitator of healthy communication. In rare circumstances, I may involve a spouse, parent, or even an adult sibling in a session in order to better understand the early developmental stages of a client to determine if there may be a need for specialized testing to rule out other conditions that may be contributing to the reported symptoms, such as neurological disorders, neurodevelopmental disorders, and learning disabilities.

Legal Issues: I am an independent clinician, and when you come to me for treatment, my work focuses on confidential personal healing. I will not get involved in legal testimony or progress reports to third parties, including through the Church for purposes of annulments and other canonical issues. This is separate from what I do as a Forensic Expert.

Cost, Length, and Frequency of Treatment: My general consultation fee is $175 per hour during the daytime and $250 per hour in the evening (if the consult starts at or after 6:00pm in Arizona) and for all concierge (on-site) services regardless of the time of day. Additional fees related to time and travel for concierge (on-site) services may apply for services outside of Flagstaff, AZ.

Sessions are usually an hour, but they can be any length, calculated at my hourly rate. I use 5-minute intervals, rounded to the next highest $5; with a minimum charge of $45. Please take note of my Payment for Services and Practice Policies for additional information.

Payment for Services: Payment can be in cash (which ensures confidentiality), by check, money order, bank draft, ACH transfer, or with a credit card. Some of these payment methods are only accepted through Square. You will be expected to pay at the time of service or in some cases, scheduling, unless other arrangements have been made. I will not prepare invoices for you, at your request, for purposes of billing, collecting payments, or “reminding” you to make a payment. In the event that there is a misuse of “other payment arrangements”, I reserve the right to require advance payment for all future sessions, use collections for past due balances, and/or terminate services.

In the event that it becomes necessary for me to prepare an invoice, in order to attempt to collect payments, you will be billed an additional $25 fee per invoice. This invoice will include the date and time of the session and the amount(s) past due. This invoice will not include information necessary for Insurance Reimbursement. For costs that I incur from my bank due to checks or other methods of payment unpaid by your bank for any reason, you will be expected to reimburse me.

If, because of rising costs, I have to raise my fees, I will not do so for current clients; but any client who leaves treatment for more than a month and then decides to return to treatment will be charged the new fee.

Practice Policies: Scheduling of your first appointment will requirement advance payment and ALL initial consultations are conducted by phone, which may be scheduled by e-mail or by calling (602) 280-9002 (voicemail-only). Please review my Communications policy prior to contacting me to schedule or to ask questions to ensure that you receive a response.

Note: If you make a donation, and you would like to schedule an appointment or explain your donation, I will not respond to the same email address that you used to make the donation.

Making a payment does not automatically guarantee that you get an appointment. That will need to be confirmed with me. [A donation is also not considered a payment for services.] All sessions must be scheduled in advance. My schedule does not allow for crisis counseling.

You will be billed for sessions cancelled without a minimum of 24-hours advance notice for consultations that are scheduled with the use of technology (phone or video conferencing) and concierge (on-site) services within the city limits of Flagstaff, AZ. You will be billed for concierge (on-site) services cancelled without a minimum of 72-hours advance notice for consultations outside of Flagstaff, AZ.

You will be billed for missed sessions. If you are late, you will be billed for the entire session. If my schedule permits and you would like to continue past the time you previously scheduled, you will be billed for the additional time spent based on the prorated hourly amount, billed in 5-minute increments, rounded to the next highest $5.

I schedule appointments Monday-Saturday throughout the early morning, daytime, and late evening. I do not schedule appointments on Sundays. I also generally do not respond to texts, emails, or voicemails on Sundays.

Insurance Reimbursement: I do not accept Medicaid, Medicare or any managed care plans. If you carry other insurance, you will still be responsible for payment of each session, in full. Then, if you request, I will provide you with a monthly statement (for a $25 fee per statement) which you can submit to your insurance company for reimbursement. This statement will include your diagnosis, the procedure code, the number of sessions, and the amount you have paid me. It will be your responsibility to contact your insurance company to determine if it will reimburse you under these terms, and, if so, what percentage of the fee it will cover.

Note, however, that your use of insurance will breach the confidentiality of your treatment because any employee of the company can demand the details of your treatment. Furthermore, insurance companies require a psychiatric diagnosis, which I believe is clinically useless but, once given to your insurance provider, will become an indelible part of your world-wide electronic medical record.

Cancellation: The scheduling of an appointment involves the reservation of time specifically for you, and I will wait the entire time for you to arrive. If you are late, we will meet for whatever time remains. You will be required to pay for the full consultation. If you do not attend your scheduled virtual consultation, which may be done by phone, audio or video conferencing, and you have not notified me at least 24 hours in advance, you will be required to pay the full cost of the service.

If you do not attend your scheduled concierge (on-site) consultation within Flagstaff, AZ, and you have not notified me at least 24 hours, you will be required to pay the full cost of the consultation (one-hour minimum). If you do not attend your scheduled concierge (on-site) consultation outside of Flagstaff, AZ, and you have not notified me at least 72 hours in advance, you will be required to pay the full cost of the consultation, unless other arrangements have been made and signed in advance by both parties. If you have requested a concierge (on-site) service that requires me to reserve travel and/or lodging, those costs are due upfront and are non-refundable.

Texting: Because of the danger of privacy breaches, I discourage the use of text messages unless they are short, information specific, and do not refer to any psychological details. In the event that you elect to use texting, it is preferable to use the Signal app or iMessages due to the enhanced privacy settings and capabilities that each provide.

E-mail: I discourage the use of e-mail with established clients. If you choose to contact me through e-mail, please understand that e-mail is not a secure form of communication and that it can be intercepted by anyone at any time. If you elect to pay with a credit card or ACH via Square, you will receive a confirmation receipt via email. Any initial invoicing to collect past due balances is also sent to your email via Square.

Audio and Video Conferencing: In addition to phone calls, I use the new Google Meet app (powered by Google Duo), which will require that you initiate a call to me from your number at the specified time of your appointment, in order to enable end-to-end encryption. If you have the old version of Google Meet on your device, you will need to uninstall it and reinstall it prior to any video conferencing or tele-health appointments to occur. I can also use Google Meet and Microsoft Teams with what is known as Transport-Layer-Security (TLS) or during transit level of encryption because I have what is known as a Business Associate Agreement (BAA) with Google and Microsoft, respectively. I do not use any other service for tele-health and other forms of video conferencing because I have not been able to find another service that is HIPAA compliant, while also being user-friendly. Microsoft Teams may add a true end-to-end encryption as early as February 2023; however, I do not have confirmation at this time.

I do not use what is known as the Client-Side-Encryption with one of Google’s partners at this time because my research indicated that all of their partners use vague language about the Health Information Portability and Accountability Act (HIPAA) regulatory requirements and how they ensure that the client (Gianna Elms, LCSW) would be in compliance by using their service as a partner with Google, even if I were to sign a BAA with them. Therefore, I am not convinced at this point in time that it actually provides a higher-level of encryption or security based on the HIPAA protections that you may have according to the law, from what I know as of this date. If something changes, I will change my policies at that time.

I occasionally use some other apps that provide end-to-end encryption for audio and video calls. I will not use Zoom for confidential audio or video calls.

Business Associate Agreements: I have what is known as a Business Associate Agreement (BAA) with necessary individuals and entities related to my websites, scheduling software, video conferencing, email, payment processing, travel, accounting, and technology related support and repair in order to protect your privacy and to be in compliance with HIPAA. While I do not keep electronic health records, your identifying information is considered Protected Health Information (PHI) and your participation in video conferencing, texting, email, and so forth are all PHI under the law. Therefore, I have made every reasonable effort to advise you about what to avoid, while also working to make my services accessible, and putting every reasonable protection in place to protect your privacy. Your privacy, safety, and healing are my top priorities.

[Revised March 2024]