This form is called a Consent for Care (the "Consent"). Your Therapist has asked you to read and sign this Consent before you start therapy. Please review the information. We encourage you to reach out with any questions or concerns.

The Illuminating Pathways is currently operating as Telehealth in a home-based office. Confidentiality laws still apply and your private information is not released to any person in the household.  Appropriate measures have been taken to create a safe and comfortable environment.

Illuminating Pathways LLC Therapy is a collaborative process where you and your Therapist will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Therapist have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between you and your Therapist. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. First, you will review your Therapist's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Therapist is practicing under the supervision of another professional, your Therapist will tell you about their supervision and the name of the supervising professional. Third, you will form a Plan of Care, including the therapeutic approaches, frequency, goals, and steps you will take to achieve them. Over time, you and your Therapist may update your Plan of Care  to be sure it describes your goals and steps you desire to take. After intake, you will attend regular therapy sessions via telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

BOUNDARIES
It is important to maintain clear boundaries to ensure a safe and professional therapeutic environment.  Please be aware of the following:

* Telehealth Sessions are conducted in a designated office space within the therapist's home, ensuring privacy and confidentiality.

* Arrival and departure times will be coordinated to maintain patient privacy and prevent encounters with other individuals in the Therapist's household.

* No personal or professional contact will occur outside of the scheduled Telehealth therapy sessions, unless explicitly agreed upon between you and the Therapist.

* There may be times where you login to the waiting room and the therapist is delayed by regulation of the current session.  When you do wait 10 minutes past your appointment time please text the therapist, they will notify you if there is a crisis and need to reschedule your session. Crisis is not predictable and advanced notice is not often able to be given.

* There may be occasional noises or interruptions that are beyond the therapist's control.  The Therapist will strive to minimize distractions to the best of their ability.

COMMUNICATION
You decide how to communicate with your Therapist outside of your sessions.

Hours of Communication Your Therapist will be available via phone Monday through Friday, 9:00 AM - 5:00 PM.  Your Therapist will respond via email and text Monday through Friday 9:00 AM - 9:00 PM.  It may be later on a case-by-case basis.  Your Therapist is not available on Saturday, Sundays or Holidays (Thanksgiving, Christmas, New Years).

Social Media/Review Websites If you try to communicate with your Therapist via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, etc. This is to protect your confidentiality and ensure appropriate boundaries in therapy.  Your Therapist may publish content on various social media websites or blogs. There is no expectation that you follow, comment on, or otherwise engage with any content. If you do choose to follow your Therapist on any platform, they will not follow you back.  If you see your Therapist on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Therapist. If you choose to leave a review of your Therapist on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing in other places without your knowledge.

Texting/Email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.  By signing this "Consent for Care" you are consenting and stating your preference to have Illuminating Pathways LLC communicate with you by email and/or standard SMS messaging regarding various aspects of your medical care, which may include, but shall not be limited to, test results, appointments, and billing.  You understand that email and standard SMS messaging are not confidential methods of communication and may be insecure.  You further understand that, because of this, there is a risk that email and standard SMS messaging regarding your medical care might be intercepted and read by a third party.

COMPLAINTS  
If you feel your Therapist has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Therapist's license, your insurance company (if applicable), or the US Department of Health and Human Services.

CONFIDENTIALITY
Your Therapist will not disclose your personal information without your permission unless required by law. If your Therapist must disclose your personal information without your permission, your Therapist will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.

* Your Therapist may speak to other healthcare Therapists involved in your care.

* Your Therapist may speak to emergency personnel.

* If you report that another healthcare Therapist is engaging in inappropriate behavior, your Therapist may be required to report this information to the appropriate licensing board. Your Therapist will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Therapist must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Therapist may not keep your personal information confidential.

* If your Therapist believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Therapist can explain more if you have questions.

* If your Therapist has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.

* If your Therapist believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Therapist will work with you to discuss other options to keep you safe.

CONSULTATION
Your Therapist may need to consult with other professionals in their areas of expertise in order to provide the best care for you. Information about you may be shared in this context without using your name.

EMERGENCY PROCEDURE
In the event an emergency occurs with your therapist, Heather Hess, LPCC, of Lives in Harmony LLC or Monica Hill LPCC-S, of Untangled Thoughts LLC, will contact you to discuss the situation and ensure you continue to receive services or are referred without significant interruption.

FEES AND PAYMENTS
You may be required to pay for services and other fees.  Fees are provided on our website, www.illuminate-pathways.com (currently under construction).  Please confirm with your insurance if part or all of these fees may be covered. You should also know about the following:

* Balance Accrual

* Full payment is due at the time of your session. If you are unable to pay, discuss with your Therapist. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.

* Insurance Benefits

* What your Insurance will and will not cover

* You may be responsible for any portion of the payment

* Your Therapist is in-network or out-of-network.

* Sharing Information with Insurance Companies

* Payment Methods

* Administrative fee for writing a letter or report at your request ($120.00 for each IPOC/medical progress report)

* Administrative fees for two (2) or more copies of records sent to third-party(ies) ($60.00 per copy)

* Consultation with another healthcare professional outside of normal practices ($120.00 per hour)

* Preparation, travel, and attendance at a court appearance ($240.00 per hour)

* No-Show and Late Cancellation Fee (price of session)

LEGAL PROCEEDINGS
Engaging in psychotherapy at Illuminating Pathway LLC does not include services related to legal proceedings, including but not limited to testimony, depositions, or providing expert opinions. Should you require your therapist's involvement in any legal matter, including court appearances or preparation, the fee for such services will be billed at a rate of $1500 per day, including time spent preparing, traveling, and waiting. These costs are typically significant and most likely will not be reimbursed by insurance. Additionally, please note that such involvement may compromise the therapeutic relationship and potentially impact the progress of your care.

You are encouraged to consider whether involving your therapist in legal proceedings is necessary and whether alternative resources, such as independent forensic evaluators/therapists, may better meet your needs.

MEASURE-BASED CARE (MBC)
Measure-Based Care checks in with how you are doing on a regular basis so you can better understand your mental health, ensure that your experience is at the center of your care,  and feel empowered as an active partner in your care process.  To provide quality of care, it is vital these assessments be completed promptly.  By signing this consent, you agree to Illuminating Pathway LLC tracking your progress via Blueprint and the CounSol EHR platform.

MINORS
Persons under 18 years of age, please be aware that the law provides for your parents to examine your therapy records. However, our experience suggests that in order for many child/adolescent clients to feel comfortable in therapy, it is beneficial to offer them the opportunity to talk with the therapist and to know that what they tell the therapist will not get back to their parents except in cases of imminent danger to the client or others, or where the therapist considers the information to be so serious that the parent's ultimate responsibility for the client's welfare dictates that the parents be kept informed. By signing this agreement, you are agreeing to this informal waiver of your right to full disclosure of the minor's records. If you choose not to informally waive this right, please talk with the therapist about your concerns prior to signing this form.

RECORD KEEPING
An electronic health record (EHR) record is maintained for each patient provided by CounSol. Your EHR will be maintained for 7 years post-discharge and destroyed per the Health Insurance Portability and Accountability Act (HIPAA).  All EHRs are stored in an off-site, HIPAA-compliant, password-secured location. A "patient record" will contain demographic, identifying, and financial data; verification of consent, identity, income, insurance; a biopsychosocial assessment; progress notes; treatment plans; level of care forms; testing instruments and results; collateral information; releases of information; and discharge summaries.  Patients may receive one copy of their record once they make this request in writing and complete and sign a Release of Information to release this private information to their custody.  Patient information and/or records will not be released to third parties without an authorized Release of Information on file, unless responding to the law, regulations set forth herein, or in the case of emergency. At all times, patient privacy will be maintained to the extent permitted by law; therefore, we will maintain the practice of only releasing what is minimally necessary.

SUPERVISION
Your Therapist may be licensed at an associate level (LPC, CT), which means they are getting supervision from an independently licensed professional (LPCC-S). If your therapist is independently licensed, this section does not apply. This supervision is to ensure that proper quality of care is being provided to you. You have the right to ask and be notified about your Therapist's license level. An associate level therapist will be receiving ongoing supervision and may be discussing your Plan of Care with his/her/their supervisor. The supervisor will have access to your progress notes and documentation but the same confidentiality and HIPAA standards apply. You have the right to refuse care from an associate level therapist. You also have the right to request his/her/their supervisor's contact information at any time. Current supervisor is Monica Hill, LPCC-S, #E-2102108-SUPV.

TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Therapist can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Therapist will recommend a different option. There are some risks and benefits to using telehealth.

Benefits  Flexibility. You can attend therapy wherever is convenient for you Therapist will need to be informed of your location for safety reasons.  Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.

Crisis Management It may be difficult for your Therapist to provide immediate support during an emergency or crisis. You and your Therapist will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.

Risks  Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Therapist carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.

Recommendations  Make sure that other people cannot hear your conversation or see your screen during sessions.  Do not use video or audio to record your session unless you ask your Therapist for their permission in advance.  Make sure to let your Therapist know if you are not in your usual location before starting any telehealth session.

Technology At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Therapist will follow the backup plan that you agree to prior to sessions.

TERMINATION
Ending a therapeutic relationship can be difficult. Therefore, it is important to have a termination process to achieve some closure. You have the right to terminate your Plan of Care at any time, after discussing it with your Therapist and communicating your request in writing. Terminating from a preferred method or procedure may result in less than optimal results. Terminating consent for your Plan of Care prevents your Therapist from providing care, and therefore, could create a lapse in treatment and potential increase in symptoms. If you are in need of urgent care and you have withdrawn your consent, your Therapist will not be able to treat you, and it will be up to you to call a crisis line or go to the hospital.

Your therapist will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose. Your Therapist has the right to terminate your Plan of Care for the following reasons:

* It is determined that the psychotherapy is not being effectively used

* Your therapist feels that he/she is not qualified or trained to treat your needs

* You are not compliant with treatment recommendations

* You violate the dual relationship boundaries or other policies stated

* Your behavior towards your therapist becomes aggressive or belligerent

* You are in default on payment

* Excessive absences and/or cancellations (3 or more consecutive)

If your therapy is terminated for any reason, or you request another therapist, you will be provided with a list of qualified psychotherapists to treat you if needed. You may also choose someone on your own or from another referral source. Should you fail to schedule an appointment for four (4) consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we will attempt to contact you for scheduling. If we are unable to reach you, we will consider the professional relationship discontinued.

TIME MANAGEMENT
Sessions are typically 45-60 minutes in length and are expected to begin and end on time.  If you arrive late for a session, your end time will not be extended.  In the event that your Therapist is tardy, your session may be extended.  The continuity of your care promotes faster healing and progress in the treatment process. So, it is beneficial for you to attend your scheduled sessions consistently.  If you cannot attend a session, you agree to notify us at least 24 hours in advance when possible.

Cancellations We reserve the right to terminate your services when you have three (3) cancellations with less than 24-hour notice.

Late Arrivals We reserve the right to reschedule your appointment when you are (10) minutes or later.  If you arrive past your appointment time, and within the (10) minute window, your session will not be extended. Unless prior arrangements are agreed to by both parties.

Transfer or Termination We reserve the right to transfer and/or terminate services at any time for any reason considered therapeutically appropriate.

Unconfirmed Appointments We reserve the right to cancel appointments that are not confirmed via text or email when you opt-in for the reminder service.

I understand that if I am uncomfortable with Telehealth in the home-based office setting at any point during our therapeutic relationship, I have the right to terminate services without prejudice.

I understand that signing this Consent for Care means I consent to receive Telehealth care by Illuminating Pathway LLC in the Therapist's home-based office.

Updated December 29,2024

NEW CLIENT WELCOME PACKET

Welcome to our practice!

Please review attached documents prior to your initial meeting. Your therapist will be 

available to answer any questions you may have. The packet includes the following: 

   1. New Client Registration Form

   2. State Of Ohio - Notice of Policies to Protect the Privacy of Your Health Information/HIPPA 

   3. Client Agreement for Services - please note that this requires you to sign in two different places to consent to treatment and to indicate that you have received all documents.

If you need a release of information or credit card authorization form, they are available on our website or directly from your therapist.

Thank you! 

Hello! My name is Robin. Starting therapy can be a scary and anxiety-provoking experience, so I want to commend you for the courage it takes to make it this far! I believe that everyone processes their thoughts and emotions in different ways, which is why I will utilize different techniques based upon the needs of the client. Illuminating Pathways is a non-judgmental, supportive, and warm environment to help clients through this fulfilling journey at their own pace. I am an eclectic therapist and utilize all therapy modalities to fit each unique Individual client's needs. Some other evidence based practices I like to utilize include but are not limited to: trauma, CBT, psychodynamic, DBT, play therapy, art therapy, and behavioral therapy. I have served clients in rural and urban environments, and with those from ages 6 to 77 years old, each with different needs, and backgrounds. I support and value diversity.  I have worked with adolescents, adults, and couples to help find your inner light.

CounSol portal
https://IlluminatingPathways.secure-client-area.com