Consent for Tele-therapy

This document outlines my office policies related to psychotherapy services being delivered remotely,

through a HIPAA secure telemedicine platform, as either a substitute for, or in addition to in-office, face-toface

visits. It will help you to understand the variety of issues involved in telemedicine, including but not

limited to: benefits, risks and limitations, method of delivery, assessment and reassessment of progress and

effectiveness, procedures when interruption of services occurs, emergency procedures/verification of

location, appropriate environment/conduct/privacy/confidentiality, fees, coverage and reimbursement

information, financial concerns when technology fails, etc.

If you have any questions about anything within this document, I encourage you to discuss them with me at

any time. As new ethical guidelines and laws are developed, this policy may be amended and you will be

notified of any policy changes both verbally and in written form.

Benefits, Risks and Limitations of Tele-Therapy

Certain circumstances may arise that lead us to determine that short or long virtual psychotherapy sessions

are clinically indicated and in your best interest.

Typically, remote counseling was used as an adjunctive treatment option in the event that one or both of us

are unable to travel to the office. However, since the national COVID pandemic, remote counseling has

become much more mainstream and a widely practiced platform for receiving therapeutic services.

Currently, I have an in-person office (located in Rockledge, FL), however, I am operating VIRTUALLY ONLY

until further notice due to being immune-compromised. Once I return to seeing individuals in person, you will

be informed and given the option to either move to in-person sessions or remain remote.

Inherent in the use of tele-therapy are certain risks and limitations, including, but not limited to:

• Lack of visual and/or audio cues, leading to misunderstanding/misinterpretation

• Delayed responses

• Technology failures that lead to disruptions and decrease the quality of the therapy session

• Confidentiality breaches if there are other people within your home

That being said, we can discuss precautions that can be taken to make the absolute most out of your remote

therapy experience. I utilize only the fastest and highest quality internet speed, as well as, only conduct

sessions in my home office with care taken to ensure that the room is soundproof and I utilize headphones.

Research supports tele-therapy as an effective psychotherapy tool. It has been shown to have similar results

as traditional face-to-face, in office therapies. But, as with in-office treatment, it varies on the person

accessing services. There are many potential benefits to engaging in remote psychotherapy services

including, but not limited to:

• Flexibility and Convenience: With tele-therapy, it's almost always in the comfort of your own home or

office. It can reduce scheduling barriers and the wait time for an appointment.

• Privacy: When special safeguards are adhered to (see below), it can be as secure as face-to-face

sessions.

• Efficiency: It eliminates the need to get in the car, on the train, or ride the bus to your appointment. As

long as you are in a private and secure space, your commute can be steps away.

• Accessibility: Remote psychotherapy allows for those who would otherwise be unable to receive mental

health services. Such as individuals who experience transportation barriers due to illness, physical

limitations, child-care challenges, lack transportation options, or reside in rural or remote areas.

Additionally, tele-therapy may also be a useful temporary substitute when the weather creates

dangerous traveling conditions.

Assessment and Reassessment of Progress and Effectiveness

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As with face-to-face, in-office treatment, your remote psychotherapy treatment plan will be individualized

and will be assessed/reassessed on a regular basis. We need to carefully monitor the effectiveness of the

treatment platform and evaluate your overall progress. As with your face-to-face, in-office visits, I may ask

you to complete brief/questionnaires/assessments about your thoughts, feelings, and behaviors. Homework

may be assigned on a more regular basis in order to supplement the work we are doing remotely. In order to

make the assessments/evaluations/homework as easily accessible as possible, and to ensure it is easy to

complete - I will be utilizing a platform called BluePrint Health, which will be discussed in it's own consent

form.

Method of Delivery of Tele-Therapy

Tele-therapy with Brianna Doran and Soul Haven Counseling & Consulting, LLC will be provided through a

HIPAA-compliant synchronous, video-conferencing platform. The platform that will be utilized is called

Sessions Health and for your convenience automatic session reminders will be sent out to remind you of the

session and a link will be sent via text message and email to connect to the session, You will be able to use

any electronic device to access the link for the session. There is no fee for clients to use this platform and is a

built in feature of the EHR I use.

• Logging in: You will click on the link that is sent - the link will be sent prior to your session (likely the day

before with a reminder the day of) - and that link will populate to our session. Once you click on the link,

you will be placed in my personal "waiting room", and I will allow you access to the actual session room

once your session begins. You are responsible for initiating the connection with me at the time of your

session. Unless I text you to inform you that I am running late, please reach out if you are having issues

with connecting. If I do not hear from you, I will assume you did not show up and you run the risk of

being charged for the session.

• Testing our your device and internet browser: Please test the link approximately 5 minutes before our

scheduled session time, and feel free to reach out to me if it is not working.

Before our first scheduled session using this platform, we can schedule a time (5 minutes or less) to briefly

test it out in the event that we need to troubleshoot any technical issues. In the past, these are the issues

that have arisen and what is recommended to rectify them:

• Internet browser connectivity issues - If your internet is not working, the tele-therapy platform will not

work unless you have cellular data on the device that you are using or a mobile hotspot that can be

connected to the device you are using.

• Choppy or frozen screen - Find a location that is close to your internet router. You may need to find a

space that consistently gets good reception.

• Low/no volume - Make sure that the volume button on your device is turned on and all the way up. I find

that using headphones or a headset greatly enhances the audio quality.

• No picture - Your camera access is turned off or blocked. Try accessing your settings and allowing your

particular device or browser permission to utilize camera access.

Procedures When Interruption of Services Occurs

In the event that technology fails or a disruption or decrease in teh quality of the session occurs while we are

engaged in remote psychotherapy, we may decide that it is best to discontinue the video session. If this

occurs, we agree that Brianna Doran or Soul Haven Counseling & Consulting, LLC will contact you by

telephone to discuss options. Therefore, it is recommended that you always have a phone available to you

and that I am advised of the best phone number to reach you at the onset of each session.

These options may include:

• Ending the treatment session

• Trying to close the platform and browser and then reconnecting to the browser and link

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• Continuing the session by phone

Emergency Procedures/Verification of Location

Your safety is my primary concern. As such, I will want to know the location (address) in which you are

located during our session. I will ask you to provide me with this information each time, but if I neglect to ask

you, I request that you inform me of your current location. I am requiring this information in the event that I

have reason to believe that you are experiencing an emergency and I need to assist you in receiving

immediate, life-saving care. In addition to providing me with your location at the outset of each remote

session, you agree to provide me with the name and contact information of a person whom I am permitted to

contact in the case that I have reason to believe you are at imminent risk. Alternatively, this information can

be kept on file.

Depending on my clinical, professional assessment of risk, I may be required to verify that your emergency

contact person is able and willing to go to your location in the event of an emergency, and if necessary, call

911 and/or transport you to a hospital. In addition, I may assess, and therefore require, that you create a safe

environment at your location during the entire time that you are in treatment with me. This may mean

disposing of all firearms and excess medication from your location.

Appropriate Environment/Conduct/Privacy/Confidentiality

Client and Brianna Doran of Soul Haven Counseling & Consulting, LLC both agree to:

• Avoid using mind altering substances during/prior to session

• Dress appropriately (shirt, pants, no low-cut or unbuttoned blouses, etc.)

• Refrain from engaging in verbally abusive ways towards individuals within the session or towards the

therapist

• Conduct the session in a suitable room, such as a kitchen, living room, bedroom or office and NOT in

public areas

• Refrain from having any other individuals present in the room or online while the remote session is being

conducted

• Not having anyone else participate in the session unless it was previously agreed upon prior to the start

of the session

• Not conducting other activities while engaged in a remote psychotherapy session, such as driving,

cooking, texting, or working

• Not audio or video recording sessions without first obtaining Brianna Doran of Soul Haven Counseling &

Consulting, LLC explicit, written consent

• Be located in the state of Florida or Vermont at the time of the session. This is because I am not licensed

in any states other than Florida and Vermont for the time being (currently working on other states). But

licensed practitioners have to follow STRICT licensing guidelines that prohibit us from providing inperson

or remote psychotherapy services to individuals not located in states we are licensed in

Violations of any of the above-mentioned conditions may result in Brianna Doran of Soul Haven Counseling &

Consulting, LLC immediately terminating the session. Dependent on the severity and frequency of the

violation, Brianna Doran of Soul Haven Counseling & Consulting, LLC reserves the right to discontinue the

therapeutic relationship.

Fees, Coverage and Reimbursement Information

Telehealth and Telemedicine Law, and state Licensing Regulations, as well as, insurance companies only

recognize Synchronous Telecommunications as valid methods to deliver tele-therapy. In order to meet the

requirement for "telemedicine", services must be provided through live, real-time, interactive, audio and

visual, two-way communications such as video teleconferencing. This means that in the event either of us

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experience connectivity issues in session, it would be appropriate to find an alternative to the telehealth

platform (such as FaceTime). However, if no other video teleconferencing option is available, we are able to

OCCASIONALLY utilize a phone call as a substitute method. However, this CANNOT be a regular occurrence

and if connectivity issues continue, it may result in needing to explore other treatment options.

Because the format for face-to-face, in-office psychotherapy sessions differ from remote psychotherapy

services, they are billed differently. They require different medical billing codes, place of service codes, and

service descriptions. This is dictated by each individual insurance company, and not by Brianna Doran of Soul

Haven Counseling & Consulting, LLC.

I will do my absolute best to obtain coverage information prior to the initial session, however, this is not

always possible. Therefore, the sole responsibility of coverage and benefits information falls completely on

you. This means that I will try my best to obtain copay/coinsurance/cost information before our initial session

- however, I may not be able to and the responsibility of knowing that information is yours. If for some reason

the insurance company denies a claim, I will do all that is in my power to determine why - however, you agree

to cover the full cost of the session in the event that the insurance company denies coverage.

Financial Concerns When Technology Fails

There will be times when we might experience connectivity issues at the outset or during the remote

psychotherapy session. If this occurs, the following billing procedures will apply:

• If we are unable to start the session due to connectivity issues, you will not be charged for the session -

provided that you inform me that you are having issues at the start of your session

• If we mutually agree to end the treatment session due to connectivity issues, you/your insurance

company will only be billed for the amount of time used

• If we try to reconnect and are successful, I will make every attempt to provide you with the full amount

of time originally scheduled for that session and you/your insurance company will be billed accordingly

• If we decide that it is in your best interest to continue the session by telephone, then the telephone

policy stated in this document applies

Telephone Sessions

The telephone is considered an asynchronous telecommunication platform and therefore does not meet the

criteria for tele-therapy. Telephone sessions may not be a covered, reimbursable benefit under your

insurance plan, and therefore should only be used in worst case scenario situations. If you request a

telephone session, you may be 100% responsible for payment and the bill that Brianna Doran of Soul Haven

Counseling & Consulting, LLC provides to you will clearly indicate that the session occurred utilizing the

telephone and did not occur via appropriate tele-therapy platform. This is why, telephone sessions should

only be used in dire conditions when no other video teleconferencing platform will work.

Please note that federal, state and regulatory laws, as well as the National Association of Mental Health

Counselor's Code of Ethics mandate that I submit accurate information to insurance companies and on billing

statements to all clients. Requests to omit factual, clinically relevant, location based or method of service

delivery information will not be granted, as this constitutes as insurance fraud, is illegal, and violates my

professional ethics code, all which could result in the loss or suspension of my license to practice mental

health counseling , substantial fines and ethical sanctions.

Conclusion

Thank you for taking the time to CAREFULLY review my Consent for Tele-Therapy Policy.

If you have any questions or concerns about and of these policies and procedures, how the EHR platform

Sessions Health works or how BluePrint Health works, I encourage you to bring them to my attention so that

we can effectively discuss.