Client Services Agreement
Welcome to Nashville Therapy Group, Inc., also known as Nashville Therapy or the Group.
This document contains important information about our professional services and business policies. It also contains information about privacy protections and client rights with regard to the use and disclosure of your personal health information.
It is very important that you read this document carefully. Please feel free to ask about anything you do not fully understand. We can discuss any questions you have, and when you sign this document, it will also represent an agreement between us.
THE THERAPEUTIC PROCESS
You have taken a very positive step by deciding to seek therapy. At your first session, you will have the opportunity to ask your therapist any questions you might have. Your therapist will ask about your reasons for coming to therapy, as well as other questions about your life, your health, and your relationship history.
Therapy experiences vary. There are many different methods that therapists may use to help you address a particular problem, and the outcome of your treatment depends largely on your willingness to engage in the process. Therapy also involves a significant commitment of time, money, and energy, so you should be careful about the therapist with whom you choose to work.
If you are ever unsatisfied with your progress, your therapist will be happy to help you set up a meeting with another mental health professional. Your decision to work with any therapist at the Group is completely voluntary. You can stop therapy at any time, and discontinuing treatment will not result in any penalty.
Therapy has both benefits and risks. The process often requires discussing the unpleasant aspects of your life, and you may experience uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness. Approaching thoughts and feelings you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with your therapist to be a source of strong feelings, some of them painful at times. It is important that you consider these risks carefully.
Of course, we believe that the benefits of therapy far outweigh the risks. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. That said, there are no guarantees regarding your experiences in therapy or the outcome of therapy. We cannot promise that your behavior or circumstance will change. We can promise to do our very best to support you, to understand you, and to help you clarify what it is that you want for yourself.
CONFIDENTIALITY
With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. We cannot and will not tell anyone else what you have disclosed or that you are in therapy without your prior written permission.
In order for any information about you to be shared, in most cases you must first sign a “Release of Information” (or ROI) that allows us to communicate only with the person identified on the release and only regarding specific information identified by you.
From time to time, we may discuss our clinical work with colleagues to make sure that we are providing our clients with the best care possible. During these consultations, we do not share your identity or personally identifiable information, and our colleagues are ethically bound to keep all information addressed in our consultation discussions confidential.
In the normal course of operations, certain business associates and non-clinical employees may have partial access to some of your personally identifiable information for the proper management and administration of our practice, including scheduling appointments, billing for services, and other general administrative purposes. This information is strictly limited to contact, calendar, and billing data. Under no circumstances do business associates or non-clinical employees ever have access to any clinical documentation or progress notes that reveal the confidential contents of your sessions with your therapist.
Under certain conditions, the laws of the State of Tennessee require exceptions to client confidentiality. These exceptions occur under the following circumstances:
1. If your therapist has good reason to believe that you will harm an identifiable person, your clinician must attempt to inform that person and warn them of your intentions. Your therapist must also contact the police and ask them to protect your intended victim.
2. If your therapist has good reason to believe you are abusing or neglecting a minor or if you give your therapist information about someone else who is doing this, your clinician must legally inform Child Protective Services.
3. If your therapist has good reason to believe you are abusing or neglecting an elderly or disabled person, or if you give your clinician information about someone else who is doing this, your clinician must legally inform Adult Protective Services.
4. If your therapist believes you are in imminent danger of harming yourself or someone else, your clinician may legally break confidentiality and call emergency services or other emergency contacts. Your therapist would explore all other options with you before taking this step. If at that point you were unwilling to take steps to guarantee safety, emergency services or emergency contacts will be called.
5. If you are involved in a court proceeding and a request is made for information regarding your therapy, such information is protected by client-therapist confidentiality. We cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss with your therapist any questions or concerns you may have now or in the future.
RELATIONAL THERAPY
When therapy occurs in a relational context (i.e., when there is more than one client in the session), you should be aware that this places additional limits on your confidentiality. For example, your confidentiality may be violated if one of the other clients in the room shares something you said in session with someone else.
If you take part in relational therapy, your personally identifiable information, which may include your reasons for seeking therapy, descriptions of the ways in which your problems impact your life, your diagnoses, your goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records, your billing records, and any documents that have been added to your case file, may also be recorded in the case files of those you are working with in therapy, including your relationship partner or family members. For example, when a therapist provides couple therapy, the names of each client, a description of what they discussed in session, and the therapist’s assessment of their relationship and reactions to treatment may appear in a joint client case file.
Most clients receive clinical services on-location at Nashville Therapy Group. However, there are times when Group clinicians provide therapy or teletherapy services at off-site locations. When this occurs, there are additional limits on confidentiality. Sessions held off-site may be more likely to be overheard by others due to building design limitations and lack of soundproofing measures such as insulation and white noise machines.
Please let us know if you have any questions about limits on confidentiality in relational therapy as well as teletherapy and off-site locations and we will do our best to answer them.
MINORS AND PARENTS
When treating a minor client (a person aged 18 and under), Nashville Therapy Group clinicians may advise a parent, managing conservator, or guardian of a minor with or without the minor’s consent, of the treatment needed by or given to a minor. If the treatment, however, is for suicide prevention; chemical addiction or dependency; or sexual, physical, or emotional abuse, the law provides that parents may not access their child’s records. For children between 16 and 18, because privacy in therapy is often crucial to successful progress, this can lead to potential problems in therapy. Older children have special rights with regard to mental health services in Tennessee. Youths 16 years and older may provide their own consents for mental health treatment. When these youths give consent, additional consent from the parent, legal guardian or legal custodian is not needed.
We will work diligently to maintain a balance between a teenager’s need for privacy/confidentiality and a parent’s desire to access their child’s records. We will work prudently with our clients to find a balance that is good for the teenager, unless we feel that the teenager is in danger or is a danger to someone else, in which case we will notify the parents immediately of our concerns.
SESSIONS
You can expect the initial assessment and evaluation period to last from 1 to 3 sessions. Sessions are approximately 50 minutes in length and typically occur weekly or every other week. Once an appointment is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation (unless both you and your therapist agree that you were unable to attend due to circumstances beyond your control). In the event of snowy or icy weather, we will follow the opening/closing schedule of Metro Nashville Public Schools, which will be communicated through local media outlets. If Nashville Therapy Group closes for inclement weather or any other reason, reasonable attempts will be made to contact you if you are scheduled for an appointment. Unless we are prevented from doing so due to an electrical or internet service failure, emergency closures will be posted on the website, nashvilletherapygroup.com.
FEES
The standard fee per 50 minute clinical hour is $300 when working with the clinical director, $150 to $300 when working with a licensed therapist, $125 to $200 when working with a pre-licensed therapist, and $50 to $150 when working with a student intern.
From time to time, therapists may offer an adjustment in their fees based on client need, though the decision to adjust the standard fee rests with the therapist and depends on several factors including the therapist’s case load and the nature of the client’s need.
If you are unsure what your fee is, your therapist will be able to tell you. The fee we charge is for each clinical hour that you are scheduled to spend in therapy. Payment is requested at the time services are rendered and may be made with cash, check, or card. We accept debit, FSA, and HSA cards as well as major credit cards (Visa, MasterCard, American Express, and Discover).
Clients sometimes request other services and there are charges for these services. The fee for report writing (psychological evaluations, treatment summaries, etc.) is $300 per hour with a minimum of one hour paid in advance. Fees must be paid in full before documents are released. Clients and/or attorneys will pay $500 per hour for courtroom testimony, with a minimum of three hours payable in advance, when honoring a subpoena and/or when providing testimony in court, regardless of whether or not the therapist actually testifies. If you or someone representing you requests your clinical record, there is a $100 processing fee.
PAYMENT
You will be expected to pay for each session at the time it is held. If your account is in arrears, your therapist will not see you for a session until you pay the balance on your account or make a payment arrangement. You will be required to pay the full fee for scheduled sessions you do not attend for which you do not provide a cancellation notice at least 24 hours prior to the session.
CONTACTING THERAPISTS
Due to our busy schedules, therapists and supervisors are often not immediately available by telephone. When we are unavailable, you may leave a voice message for us at 615-492-6700 and we will return your call. We will make every effort to return your call within 24-48 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are in an emergency, or if you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room (i.e., call 911) or call the Tennessee Office of Crisis Services and Suicide Prevention at 855-274-7471.
At Nashville Therapy Group, therapist and supervisor email accounts are secured by Google according to industry standards. We do ask you to please remember that there is always a risk of a breach of confidentiality whenever you share your personal information. We also want you to be aware that your email account may not be secured according to health industry standards. Therefore, please use discretion and reveal only the minimum necessary personal information when communicating via email. Emails sent to therapists and supervisors at Nashville Therapy Group are saved and may be included in your clinical record.
EVIDENCE-BASED PRACTICE
All therapists at the Group practice an evidence-based approach to therapy. This means their treatment plans for you are significantly influenced by scientific theory and research. Your therapist may ask you to complete brief questionnaires that let us know how you feel about your life in general, your relationships with others, and your experience in therapy. We use this information to monitor your progress and to inform our decisions as we try to help you reach your goals. We look forward to finding out what therapy can help you accomplish.
COMPLEMENTARY AND ALTERNATIVE SERVICES
Nashville Therapy Group is committed to providing our clients with a range of complementary and alternative services to complement and enhance their traditional mental health care. These services are provided by holistic or integrative practitioners who are not therapists and may not be certified or licensed by any governmental body. Our complementary and alternative services may include but are not limited to:
1. Herbal consultations by practitioners who may help to identify herbs and herbal formulations to support your specific health needs.
2. Nutrition consultations by practitioners who may help you to develop a healthy and balanced eating plan that aligns with your individual health goals.
3. Wellness consultations by practitioners who may provide guidance and support on a variety of topics, including stress management, sleep hygiene, and exercise.
4. Yoga consultations by practitioners who may guide you through various yoga postures, breathing techniques, meditation, and relaxation exercises.
5. Breathwork consultations by practitioners who may teach a variety of conscious breathing techniques to improve physical and emotional health.
6. Spiritual consultations by practitioners who may offer guidance and support for clients who are seeking a deeper connection to their spiritual selves.
Please note that these services are offered separately from traditional mental health care services. Prior to engaging any complementary or alternative services by a holistic or integrative practitioner, you will be asked to review and sign additional informed consent documentation disclosing the practitioner's level of training, certification or licensure status, and scope of practice.
CLINICAL RECORDS
We keep your Personal Health Information (PHI) in an Electronic Health Record (EHR) using SimplePractice, a cloud-based, practice management service. Your EHR contains PHI that may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, any reports that have been sent to anyone, and other sensitive information. This clinical record is kept for seven years post treatment for adult clients and for ten years past the 18th birthday of minor clients. Except in unusual circumstances that involve danger to yourself or others, you may examine and/or receive a copy of your clinical record if you request it in writing. Therapists and supervisors at Nashville Therapy Group charge a $100 fee for locating and copying your clinical file. If we refuse your request to obtain a copy of your clinical record, you have a right of review, which we will discuss upon your request. In addition to your EHR, we maintain an electronic directory of client contact information and other information including your name, address, email address, ID number, the date we opened your case file, the date we closed your case file (if applicable), and whether you are currently attending therapy sessions with a therapist at Nashville Therapy Group. We also keep electronic records of the number of therapy sessions you have received and other information including your ID number, dates of service, fees charged, fees you paid, cancellations, and missed sessions.
In addition to the clinical record, your therapist may also keep a set of psychotherapy notes. These notes are for the therapist’s use and are designed to assist in providing you with the best treatment possible. While the contents of the notes vary from client to client, they can include the contents of your conversations with your therapist and his or her analysis of those conversations. Psychotherapy notes may also contain particularly sensitive information that you may reveal to the therapist that is not required to be included in your clinical record. These notes are kept separate from your clinical record and are not typically released to others. You may examine and/or receive a copy of your psychotherapy notes unless it is determined that releasing them would be harmful to your physical, mental, or emotional health.
CASE FILE CLOSING
When client case files are inactive for a period of 5-weeks or more, we close the case file. Normally, case files can be reopened at any time should a client decide to return to therapy. If we are not able to reopen your case file for whatever reason (e.g., limited therapist availability), we will be happy to provide you with a referral to see another therapist. Once closed, client case files and other personally identifiable information is kept for 7 years after a client’s final session if the client is 18 years of age or older and for 10 years after the client’s 18th birthday if the client is under 18 at the time of treatment.
CONSENT TO THERAPY
I have fully read and agree to the terms outlined in this Client Services Agreement & Consent to Treatment and give consent for therapy. I have discussed any questions I had with my therapist at Nashville Therapy Group and I understand the information in this consent form. Furthermore, I understand that my therapist will abide by the above mentioned policies, procedures, and techniques in providing my treatment. I hereby release Nashville Therapy Group, Inc. and the other officers, agents, representatives, and employees as custodians of my clinical record for the period of seven years post treatment, both individually and collectively, from any and all liability for damages of whatever kind may at any time result to me, my heirs, family, or associates because of compliance with this authorization for treatment and any other attempt to comply with it. My signature below indicates that I give my informed consent for treatment with my therapist at Nashville Therapy Group for myself and any of my minor children I bring to therapy to receive services as discussed above.
Further, I do for myself and my personal representatives, heirs and assigns, hereby agree to indemnify, defend, hold harmless, release, forever discharge and covenant not to sue Nashville Therapy Group, its officers, agents, representatives and employees from and against any and all losses, claims, demands, actions and damages, including reasonable attorneys’ fees, arising out of or related to the services rendered for me by my therapist.
EFFECTIVE DATE
This agreement is dated April 1, 2020.
Consent for Telehealth and Technology Services
This document contains important information about the use of telehealth and other technology services we may use in our practice.
TELEHEALTH SERVICES
Telehealth by SimplePractice, Sessions by Psychology Today, and Google Meet are the services we may use at Nashville Therapy Group to conduct telehealth video-conferencing appointments. By signing this document, you understand and acknowledge:
1. Your therapist may wish to engage with you in a telehealth session.
2. Telehealth sessions will not be the same as in-person visits due to the fact that you will not be in the same room as your therapist.
3. Telehealth sessions have potential benefits including easier access to care and the convenience of meeting from a location of your choosing.
4. There are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. As such, you or your therapist can discontinue the telehealth session if the video-conferencing connections are not deemed adequate for the situation.
5. You have had the opportunity to ask questions about telehealth services. Your questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with you in a language that you understand.
6. Telehealth by SimplePractice, Sessions by Psychology Today, and Google Meet are NOT Emergency Services and in the event of an emergency, you will use a phone to call 911.
7. To maintain confidentiality, you will not share your telehealth appointment link with anyone unauthorized to attend the appointment.
OTHER TECHNOLOGY SERVICES
In addition to telehealth services, Nashville Therapy Group may use Mentalyc’s note-taking system as part of our effort to provide the best care to our clients. Mentalyc is a technology service that provides automatically generated transcripts and summarizations of therapy sessions. Mentalyc’s system is HIPAA compliant and uses up-to-date encryption methods, firewalls, and backup systems to help keep your information private and secure. Your therapist may record your session for the purposes of transcription and summarization using Mentalyc’s HIPAA-compliant technology. Mentalyc does not store the recordings or any of your personal information. Your therapist may choose to keep the summarized notes as part of your confidential medical record.
CONSENT FOR TELEHEALTH AND TECHNOLOGY SERVICES
I have fully read and agree to the terms outlined in this Consent for Telehealth and Technology Services and give my consent for use of Telehealth by SimplePractice, Sessions by Psychology Today, and Google Meet. I also give my consent for my therapist to record our sessions and to use the Mentalyc software. I have discussed any questions I had with my therapist and/or Nashville Therapy Group, Inc. staff, and I understand the information in this consent. I acknowledge and agree that Nashville Therapy Group, Inc. and its therapists and staff cannot guarantee the privacy and confidentiality of any communication through Telehealth by SimplePractice, Sessions by Psychology Today, Google Meet, or Mentalyc and hereby hold harmless and release Nashville Therapy Group, Inc. and all its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any breach of privacy or confidentiality in connection therewith.
EFFECTIVE DATE
This agreement is dated April 1, 2020.