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Terms and Policy

Payment
An invoice will be generated when your appointment is scheduled. Payment is expected no later than at the time of service. Termination of services will occur if payment is not made in a timely manner. Initial, in-office consults and client-requested indoor appointments require a $50, nonrefundable deposit. 

Payment may be made by PayPal via the client portal, or by cash, credit card, or check at time of service. A returned check fee of $25.00 applies to payment returned for insufficient funds (NSF). Receipt for services may be viewed and/or printed via the client portal within 24 hours of client session.

**Sole to Soul Therapy & Consulting, LLC does not bill private insurance but you may view and print invoices via your client portal to submit to your insurance company for reimbursement of their allowable amount. Please note that telephone sessions are not typically reimburseable by health insurance.

These terms and conditions are subject to change.

I have read and agree to these terms and conditions.
( Type Full Name )
Cancellation
Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.

If you present to an appointment more than 15 minutes after it is scheduled to begin your appointment will be cancelled and you will be billed for the full session.

Most insurance companies do not reimburse for missed sessions.

These terms and conditions are subject to change.

I have read and agree to these terms and conditions.
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Office Hours and After Hours Emergency Contact Information
Denice's regular office hours are Monday through Thursday 9:00 a.m. to 5:00 p.m.

Denice manages her own appointments via the online client portal or you may leave a message on her cell (404-895-1525) requesting an appointment. If you prefer an appointment time not currently listed on the client portal you may message Denice or call and ask for an alternate appointment time (Ex., evening or weekend) subject to her availability.

If you are experiencing an emergency, please call either 911; LifeLine (1-800-273-8255); Behavioral Health Link (1-800-715-4225); the Fulton County Crisis Line (404-730-1600 or 404-730-1608); or go to your nearest emergency room. Please do not message Denice via the client portal, text, or leave a message for an emergency situation. She may not receive your message until some time later as she may be seeing other clients or she may not check messages after hours.

Terms and conditions are subject to change.

I have read and agree to these terms and conditions.
( Type Full Name )
Notice of Privacy Practices
Sole to Soul Therapy & Consulting, LLC
Denice Crowe Clark, LMFT, DCC
404-895-1525
www.walkandtalkatlanta.com

Notice of Privacy Practices

Your information. Your rights. Your responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your have the right to:
Get a copy of your paper or electronic medical record.
Correct your paper electronic medical record.
Request confidential communication.
Ask me to limit the information I share.
Get a list of those with whom I’ve shared your information.
Get a copy of this privacy notice.
Choose someone to act for you.
File a complaint if you believe your privacy rights have been violated.

You have some choices in the way that I use and share information as I:
Tell family and friends about your condition.
Provide disaster relief.
Include you in a hospital directory.
Provide mental health care.
Market my services and sell your information.
Raise funds.

I may use and share your information as I:
Treat you.
Run my organization.
Bill for your services.
Help with public health and safety issues.
Do research.
Comply with the law.
Respond to organ and tissue donation requests.
Work with a medical examiner or funeral director.
Address worker’s compensation, law enforcement, and other government requests.
Respond to lawsuits and legal actions.

Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.

Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this. I will provide a copy or summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.

Ask me to correct your medical record: You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this. I may say “no” to your request, but I will tell you why in writing within 60 days.

Request confidential communications: You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.

Ask me to limit what I use or share: You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.

Get a list of those with whom I have shared information: You can ask for a list (accounting) of the times I have shared your health information for six years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). I will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has thi authority and can act for you before we take any action.

File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting us using the information at the top of this page. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S. W., Washington, D. C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/ . I will not retaliate against you for filing a complaint.

Your Choices: For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

In these cases, you have both the right and choice to tell me to:
Share information with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.
Include your information in a hospital directory.
If you are not able to tell me your preference, for example, if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases I never share your information unless you give me written permission:
Marketing purposes.
Sale of your information.
Most sharing of psychotherapy notes.

In the case of fundraising:
I may contact you for fundraising efforts, but you can tell me not to contact you again.

My Uses and Disclosures: How do I typically use or share your health information? I typically use or share your health information in the following ways.

Treat you: I can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run my organization: I can use and share your health information to run my practice, improve your care, and contact you when necessary. Example: I use health information about you to manage your treatment and services.

Bill for your services: I can use and share your health information to bill and get payment from health plans or other entities. Example: I give information about you to your health insurance plan so it will pay for your services.

How else can I use or share your health information? I am allowed or required to share your information in other ways—usually in ways that contribute to public good, such as public health and research. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues: I can share health information about you for certain situations such as preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect or domestic violence; preventing or reducing a serious threat to anyone’s health or safety.

Do research: I can use or share your information for health research.

Comply with the law: I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I am complying with federal privacy law.

Respond to organ and tissue donation requests: I can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director: I can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests: I can use or share health information about you for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; for special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions: I can share health information about you in response to a court or administrative order, or in response to a subpoena.

My Responsibilities:

I am required by law to maintain the privacy and security of your protected health information.

I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

I must follow the duties and privacy practices described in this notice and give you a copy of it.

I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Le me know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of this Notice
I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request on my website and patient portal.

This Notice of Privacy Practices applies to the following organization:
Sole to Soul Therapy & Consulting, LLC
( Type Full Name )
Informed Consent to Treatment
Sole to Soul Therapy & Consulting, LLC
Denice Crowe Clark, LMFT
1201 Peachtree St, Suite 200
Atlanta, GA 30361
404-895-1525

Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for Psychotherapy

This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Denice Crowe Clark, LMFT that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Denice Crowe Clark, LMFT. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Denice Crowe Clark, LMFT will use her clinical judgment when revealing such information. Denice Crowe Clark, LMFT will not release records to any outside party unless she is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Denice Crowe Clark, LMFT becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided on the biographical sheet.




HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims for reimbursement. If you so instruct Denice Crowe Clark, LMFT, only the minimum necessary information will be communicated to the carrier. Denice Crowe Clark, LMFT has no control over, or knowledge of, what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Denice Crowe Clark, LMFT to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

CONSULTATION: Denice Crowe Clark, LMFT consults regularly with other professionals regarding her clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

E-MAILS, CELL PHONES, COMPUTERS AND eFAXES: It is very important to be aware that computers and unencrypted email, texts, and e-faxes communication (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on Denice Crowe Clark, LMFT's laptop is encrypted, emails, texts and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Denice Crowe Clark, LMFT's laptop is equipped with a firewall, a virus protection and a password, and she backs up all confidential information from her computer on a regular basis onto an encrypted hard-drive. Please notify Denice Crowe Clark, LMFT if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, Denice Crowe Clark, LMFT will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and she will honor your desire to communicate on such matters. Please do not use texts, email, voice mail, or faxes for emergencies. Messages sent via the online patient portal are, however, encrypted.

RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Denice Crowe Clark's profession require that she keep treatment records for at least 10 years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, Denice Crowe Clark, LMFT retains clinical records only as long as is mandated by Georgia law. If you have concerns regarding the treatment records, please discuss them with Denice Crowe Clark, LMFT. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Denice Crowe Clark, LMFT assesses that releasing such information might be harmful in any way. In such a case, Denice Crowe Clark, LMFT will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Denice Crowe Clark, LMFT will release information to any agency/person you specify unless Denice Crowe Clark, LMFT assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Denice Crowe Clark, LMFT will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Denice Crowe Clark, LMFT between sessions, please leave a message on her voicemail at (404) 895-1525 and your call will be returned as soon as possible. Denice Crowe Clark, LMFT checks her messages a few times during the daytime only, unless she is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call Lifeline (1-800-273-8255); Behavioral Health Link (1-800-715-4225); Fulton County 24-hour crisis line (404) 730-1600 or (404) 730-1608); or the Police: 911. Please do not use email or faxes for emergencies. Denice Crowe Clark, LMFT does not always check her email or faxes daily.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard session fees ($150 initial one-hour consult, $100.00 per 45 minute walk-and-talk session, or $150.00 for client-requested indoor 45-minute sessions) at the end of each session unless other arrangements have been made. Initial consult and client-requested indoor sessions require a $50, non-refundable deposit. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at $150 per hour, unless indicated and agreed upon otherwise. Please notify Denice Crowe Clark, LMFT if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently receipts for payment may be downloaded at your convenience from the client portal. You may then submit these to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Denice Crowe Clark, LMFT can use legal or other means (courts, collection agencies, etc.) to obtain payment.



MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Denice Crowe Clark, LMFT and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Fulton County, Georgia in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Denice Crowe Clark, LMFT can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Denice Crowe Clark, LMFT will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Denice Crowe Clark, LMFT may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Denice Crowe Clark, LMFT is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Denice Crowe Clark, LMFT provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Denice Crowe Clark, LMFT will discuss with you her working understanding of the problem, treatment plan, therapeutic objectives, and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, possible risks, Denice Crowe Clark, LMFT's expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION: As set forth above, after the first couple of meetings, Denice Crowe Clark, LMFT will assess if she can be of benefit to you. Denice Crowe Clark, LMFT does not work with clients who, in her opinion, she cannot help. In such a case, if appropriate, she will give you referrals that you can contact. If at any point during psychotherapy Denice Crowe Clark, LMFT either assesses that she is not effective in helping you reach the therapeutic goals or perceived you as non-responsive, and if you are available and/or it is possible and appropriate to do, she will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, she would give you a couple of referrals that may be of help to you. If you request it and authorize it in writing, Denice Crowe Clark, LMFT will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, Denice Crowe Clark, LMFT will give you a couple of referrals that you may want to contact, and if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, Denice Crowe Clark, LMFT will provide you with names of other qualified professionals whose services you might prefer.

DUAL RELATIONSHIPS: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Denice Crowe Clark, LMFT's objectivity, clinical judgment or can be exploitative in nature. Denice Crowe Clark, LMFT will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual and rehabilitation communities, etc., multiple relationships are either unavoidable or expected. Denice Crowe Clark, LMFT will never acknowledge working with anyone without his/her written permission. Many clients have chosen Denice Crowe Clark, LMFT as their therapist because they knew her before they entered therapy with her, and/or are personally aware of her professional work and achievements. Nevertheless, Denice Crowe Clark, LMFT will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise Denice Crowe Clark, LMFT if the dual or multiple relationship becomes uncomfortable for you in any way. Denice Crowe Clark, LMFT will always listen carefully and respond to your feedback and will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.

SOCIAL NETWORKING AND INTERNET SEARCHES: At times, I may conduct a web search on my clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss them with me. I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites can compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully (a total of 6 pages); I understand them and agree to comply with them:
( Type Full Name )