I authorize L. Breanne Bass, LCSW of Oak Counseling LLC to process the card on file at the rate of agreed upon charges. I understand this will occur per each session, and when qualifications are met for a missed session or late cancellation.

I understand Oak Counseling, LLC does not work with insurance. I understand I will receive a receipt of services and may submit this to insurance, but this does not guarantee reimbursement as reimbursement is approved or denied by my own insurance provider/policy.

I understand I may change the card on file or choose to pay via check or cash at time of session, as opposed to having the card on file charged post session.

Overview
The therapeutic relationship is unique in that it is highly personal, while following ethical, professional, and personal boundaries. This consent form will provide a clear framework for the therapeutic relationship and expectations within it. Please feel free to discuss any of this with me at any time.

Therapy can offer support, education, and practical tools along with so much more. Please note, you (and or) your child's engagement is a vital part of this. Please also note progress is not linear, and may shift per goals, life situations, and changes in engagement level and attendance. I can not guarantee the changes you seek will be made, but can guarantee my support for the process and commitment to aid in understanding your personal journey to best support your (and or your child's) goals.

Confidentiality
The session content and all relevant materials to the client's treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are specified below:
   1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
   2. If a client threatens grave bodily harm or death to another person.
   3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
   4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
   5. Suspected neglect of the parties named in items #3 and # 4.
   6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
   7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Occasionally, It may be important to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or any personal or identifying information.

Should we see each other outside the office or virtual appointments, I will not acknowledge you first in order to protect your right to privacy. Should you choose to acknowledge me, I will be happy to greet you.

Communication
Provided below is my contact for scheduling concerns or emergency concerns. Your client portal email is the most secure way to reach me, and I will respond via phone as appropriate. Below are additional forms of communication.

Email: l.breannebass@proton.me
Phone Number: 804-446-0523

Please note below are emergency numbers for 24/hour crisis concerns as I may not always be accessible immediately outside session hours. If you are having a mental health crisis, please contact 911 first and then reach out to me. I have also provided 24 hour contacts below for outside session support not requiring emergency 91. Oak Counseling is not a crisis center and may not be readily available for crisis. I am available to support connection to crisis resources, ongoing coping skills, and safety plans per client treatment needs.

24 hour emergency contacts.
Crisis text line, text home to 741-741
Suicide Crisis line, 988
The trevor lifeline for LGBTQI+1-866-488-7386
The trans lifeline,877-565-8860
Domestic Violence, 800-799-7211

Technology Agreement
You authorize Oak Counseling to contact you by phone using the number you provide at intake. Though no confidential information will be shared via message or voice mail,  please let your therapist know should you wish to not receive any form of message. Text reminders will be sent out prior to. If you wish to not receive this, please inform your therapist.

Even though Oak Counseling has secured an encrypted email system, email is not the most secure way of communication. Any emails sent may also be considered part of the client file. You are welcome to email me, but be aware of the risks and understand the therapist will not provide therapy via email.

Text messaging is a popular and convenient form of communication. If you choose to text your therapist, this information is at risk and not considered a confidential mode of communication. Your therapist at Oak Counseling will engage in text messages regarding scheduling only. Please do not send updates or personal information through text. Therapists will not provide therapy via text message.

Using the Counsole Portal is the most secure way of electronic communication. These messages come directly to your therapist.

Video sessions will be held via your secure client portal. Please note, we utilize all precautions on our end to keep your video session private such as sound machines and private space. It is your responsibility to ensure your environment is secure for confidentiality.  Video sessions will not be recorded by any party.

Social Media friend requests will not be accepted. This is in order to protect your confidentiality and respect of boundaries as much as possible.

Fees, Cancellation, Missed Sessions
 - A intake session, (first session to develop treatment plan and possible diagnosis) will be charged a rate of 175
 - A full 50 minute session will be charged at a rate of 135
 - A half hour session will be charged at a rate of 75

In order to aid in making therapy accessible, a receipt of services will be sent out post each session. You may provide this to your insurance company per their reimbursement policy. I do not guarantee reimbursement as I cannot speak to the individual policy you hold, as individual reimbursement policy varies.

I politely request a 24 business hour cancellation notice and arrival no later than 10 minutes past your session time in order to avoid a missed session fee. Please note, the card on file will be charged should this occur at a rate of $75 for a last minute cancellation, and full session rate for no shows and hour of cancellations. If you have a recurring appointment spot, you will need to call and reschedule after two consecutive absences.

Please note, future sessions may be canceled if payments are not processed. Please reach out should this occur!

If you are opting in to utilize Anthem, please note a card is still required on your client portal for no show or cancelations.

Signature
Signing this form, states you understand and agree to the above listed information, and understand your access to inquire about any above mentioned topics at any time.

Your Information. Your Rights. Our 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 Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our 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 we have about you. Ask us how to do this.
 - We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
 - You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
 - We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications
 - You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
 - We will say "yes" to all reasonable requests.

Ask us to limit what we use or share
 - You can ask us not to use or share certain health information for treatment, payment, or our operations.
      - We are not required to agree to your request, and we may say "no" if it would affect your care. 
  - If you pay for a service or health care item outof-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
      - We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information
 - You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
 - We 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). We'll 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. We 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.
 - We will make sure the person has this 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 on the back 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/.
 - We will not retaliate against you for filing a complaint.

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

In these cases, you have both the right and choice to tell us 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 us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
 - Marketing purposes - Sale of your information - Most sharing of psychotherapy notes In the case of fundraising:
 - We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you
 - We 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 our organization
 - We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

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

How else can we use or share your health information?
We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we 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
 - We 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
 - We can use or share your information for health research.

Comply with the law
 - We 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 we're complying with federal privacy law.

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

Work with a medical examiner or funeral director
 - We 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
 - We 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
 - We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
 - We are required by law to maintain the privacy and security of your protected health information.
 - We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
 - We must follow the duties and privacy practices described in this notice and give you a copy of it.
 - We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us 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
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This Notice of Privacy Practices applies to the following organizations.
Oak Counseling, LLC