Phone: 855.593.4357 • MyCounselor.Online
Revised 01-03-2024
About Informed Consent
About MyCounselor.Online
Our Leadership
The Services We Provide
Our Statement of Faith
Our Code of Ethics
Counselor Qualifications, Credentials, and Associations
Consent To Christian Counseling
State-Licenses
Terms
Consent to Christian Counseling
Standards of Competent Service
Services the counselor will provide
Goals of the therapeutic relationship
Risks and benefits of therapeutic procedures
Policies and Procedures
Client behavior expected
Physical Evaluation
Financial Considerations
Payment Arrangements
Fees
Membership Fees
Additional Session Fees (Member Rate)
Non-Member Fee Rates
Automatic Credit Card Billing Authorization
Credit or Debit Card Authorization
eCheck Authorization
Appointment Cancellation / Reschedule Policy
Membership Cancellation & Refund Policy
Risk-Free Guarantee
Price Increases
Counselor Advancement
Inflation & Cost of Living
Insurance Reimbursement
Electronic & Phone Sessions
Non-Discrimination
Sexual Conduct
Contacting Your Counselor & Member Support
Confidentiality
Electronic Communication
Supervision, Training, and Quality Assurance
Supervision & Consultation
Taping or recording of sessions
Minors Confidentiality
Couples Therapy Confidentiality
No Secrets Policy
Individual Sessions & Couples Counseling
Court Proceedings/Subpoena of Records
Release of Records
Group Therapy Confidentiality
Notice of HIPAA Privacy Practices
Uses and Disclosures for Treatment, Payment and Health Care Operations
Authorization to Leave a Message with Protected Health Information
Other uses and Disclosures Requiring Authorization
Uses and Disclosures with Neither Consent nor Authorization
Patient’s rights and Therapist’s Duties
MyCounselor.Online Duties
Complaints
Effective Date, Restrictions, and Changes to Privacy Policy
SMS Opt-In
Website Privacy Policy and Terms of Service
Consent and Agreement to Terms of Service
At MyCounselor.Online we believe it is important you be informed in writing about our company, policies, and our services before you decide to consent to services with us. We call this informed consent.
This is our written informed consent document and terms of service. Please read it carefully and ask our Member Support team any questions you have about it before signing. This document is an agreement between you and MyCounselor.Online for the services you receive from us.
You can reach our Member Support Team by calling 855-593-4357 or emailing receptionist@mycounselor.online
IMPORTANT
Each person receiving services must acknowledge and consent to the terms of services contained in this document in writing by electronically signing this document BEFORE you can receive services from MyCounselor.Online.
MyCounselor.Online was founded by Josh and Cassie Spurlock in 2008 in Springfield, Missouri. The company is governed by the board of Partners For Strong Families, a Missouri 501(c)3 Not For Profit Foundation.
Josh Spurlock provides operational and clinical oversight as Founder and CEO for the company. He is educated with a Bachelors degree in Biblical Languages, a Masters degree in professional counseling, Certification as a Sex Therapist (ABCST), advanced training in Emotion Focused Therapy (EFT), Accelerated Experiential Dynamic Psychotherapy (AEDP), and is the developer of Neuroscience Informed Christian Counseling (NICC). Josh is ordained as a minister and licensed as a mental health professional in Missouri (LPC), Colorado (LPC), and Florida (LMHC).
You can contact Josh & Cassie by:
Counseling
MyCounselor.Online is a faith-based provider of Christian Counseling for mental health and personal development primarily online over the internet using video conferencing technology.
As a provider of religious counseling services our services are not regulated by any state or federal government agency by virtue of the free exercise clause of the first amendment to the U.S. Constitution, protecting religious liberty.
Our model for counseling is Neuroscience Informed Christian Counseling (NICC). You can learn more about NICC on our website here: https://mycounselor.online/nicc/
Mental Health CoachingThe mental health coaching provided by MyCounselor.Online is provided by coaches trained and supervised through MyCounselor.Online’s internal training program. MyCounselor.Online mental health coaches may or may not have additional training and experience in coaching consistent with the International Coaching Federation (ICF) or pastoral counseling experience. Coaches are generally not trained in counseling and will make referral to counseling staff when appropriate. Unless otherwise specified all policies relevant to MyCounselor.Online counselors also apply to coaches, including but not limited to confidentiality and it’s limits.
Our Statement of Faith does not exhaust the extent of our beliefs. The Bible itself, as the inspired and infallible Word of God that speaks with final authority concerning truth, morality, and the proper conduct of mankind, is the sole and final source of all that we believe. For purposes of MyCounselor.Online’s faith, doctrine, practice, policy, and discipline, our Founders are the final interpretive authority on the Bible’s meaning and application.
At MyCounselor.Online we practice in accordance with the ethics and standards defined in the American Association of Christian Counselors Code of Ethics.
Qualifications, credentials, and associations will vary upon who your counselor is. Please reference the bios of each professional on the MyCounselor.Online website for the qualifications, credentials, and associations of your specific counselor.
If you have any questions about your counselor’s experience, training or education feel free to ask them as they arise
MyCounselor.Online provides religious-based, specifically Christian, counseling in-person and online.
As providers of religious-based counseling, the services we provide require no government licensure from the state or federal government.
Religious based counseling is not regulated by the government by virtue of the free exercise clause of the first amendment to the U.S. Constitution.
Although not required for providing religious-based counseling, MyCounselor.Online believes the education and experience standards for mental health state licensure are valuable benchmarks for the training of counselors. Thus, our internal certification process is built to meet or exceed the mental health state-licensure requirements in all 50 states. We also encourage and facilitate our counselors in pursuit of licensure in the states they physically reside.
Regardless of what state licensures employees may hold, the counsel provided through their employment with MyCounselor.Online is religious-based counsel protected under the free exercise clause of the first amendment to the U.S. Constitution and is not in capacities related to their state-license.
If your counselor is state-licensed, they will be licensed in the state(s) in which they physically practice. They may not be licensed with the state you are physically present in when accessing services via online counseling. Regardless of where you physically are when accessing counseling services online, we understand you to be "coming to" your counselor, by way of the technology, in the state they are physically present. By electing to receive services you consent to counseling with this understanding. You can find the state licensure status for each counselor under their profile on our website.
The terms, counsel, counseling, therapy, religious-based counseling, faith-based counseling, and Christian counseling, as used by MyCounselor.Online, are interchangeable and refer to the delivery of religious-based counseling provided to you in accordance with your free exercise of religion.
The terms counselor and therapist are also used interchangeably and refer to employees of MyCounselor.Online who provide religious-based counseling services to clients and who may or may not be state-licensed mental health providers. Our use of the adjective ‘professional’ is intended to communicate the quality of professionalism our counselors provide services with and is not a reference to state-licensure.
In signing this document and accepting services from MyCounselor you acknowledge your intent to receive religious-based counseling in accordance with the free exercise of your religion. Further, you grant permission for MyCounselor to provide services in accordance with the principles of Christian Counseling as defined in the MyCounselor.Online Statement of Faith and the American Association of Christian Counselors Code of Ethics 2014.
Counseling is not easily described in general statements. It varies depending on the personalities of the counselor and client, and the particular problems you bring forward. There are many different methods your counselor may use to deal with the problems that you hope to address. Counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the counseling to be most successful, you will have to work on things we talk about both during our sessions and at home.
Your first few sessions will involve an evaluation of your needs. By the end of the evaluation, your counselor will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with counseling. You should evaluate this information along with your own opinions of whether you feel comfortable working with your counselor.
Counseling involves a large commitment of time, money, and energy, so you should be very careful about the counselor you select. If you have questions about MyCounselor.Online procedures, you should discuss them whenever they arise. All counselors of MyCounselor.Online have been trained to know a variety of methods and techniques. Your counselor will determine from his or her assessment of your situation and through consultation if deemed beneficial, which is the most effective for you.
Your counselor will work with you to determine the goals you would like to set for counseling and to help you achieve those goals. While the length of treatment is difficult to determine, your counselor will be happy to discuss this and the style of treatment with you.
Counseling can have both benefits and risks. Since counseling often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, counseling has also been shown to have considerable benefits for people who go through it. Counseling often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. You may, at any time, seek a second opinion and/or terminate treatment.
Your counselor will normally conduct an evaluation during the first few sessions. During this time, both you and your counselor can decide if he or she is the best person to provide the services you need to meet your goals for counseling.
Once counseling begins, your counselor will usually recommend scheduling one to four 45-minute sessions per month (4 weeks) at times you agree on.
Once an appointment is scheduled, you will be expected to pay for it unless you give notice of cancellation at least 24 hours before your scheduled appointment. Sessions will begin at the time scheduled. If the counselor causes a late start, the session will still last for 45 minutes. If you arrive late for your appointment, the session will have to end at the regularly scheduled time, and the charge will be for the full amount of the appointment fee.
It is strongly recommended that you be current on your physical examinations from your personal physician. This is important to make sure none of the problems discussed are the result of physical health difficulties. Your counselor is not a physician and will not use physical interventions such as medications. When medications are appropriate your counselor will work closely with your physician.
Your fees will depend on the specific counselor you see. Please reference the MyCounselor.Online Pricing page for details at https://mycounselor.online/pricing/. The additional session charges that apply to counseling also apply to other professional services you may need. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of MyCounselor.Online. At times it may be necessary to briefly speak to your counselor by telephone, for which there is no charge. However, when phone counseling occurs, the fees will be the same as for regular sessions. If you become involved in legal proceedings that require MyCounselor.Online participation, you will be expected to pay for the professional clinical time even if your counselor is called to testify by another party.
Your monthly membership fee will be billed every 4 weeks beginning on your membership start date. Each billing cycle your account will be credited for 2 45 minute units of counseling. The morning of your scheduled appointment your account will be debited for your scheduled session. Unused units roll over to the next billing cycle. Accumulated sessions never expire so long as you remain an active member. If you have exhausted your sessions credits for the cycle the payment method you have provided will be automatically charged an additional session fee at that time for the additional session you scheduled.
You must keep a valid and active payment form on account at all times.
If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, MCO has the option of using legal means to secure the payment. This may involve hiring a collection agency or going to small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If you have a question about these costs please feel free to speak to your counselor.
I hereby authorize Paraclete Ministry Group LLC, dba MyCounselor, to automatically bill the card I have provided to MyCounselor. I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this agreement.
I authorize Paraclete Ministry Group LLC, dba MyCounselor, to automatically initiate either an electronic debit or to create and process a demand draft against my bank account using the routing and account number I have provided. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.
I understand that if I fail to give notice of cancellation or rescheduling requests by using the scheduling software link, calling 855-593-4357, or emailing receptionist@mycounselor.online at least 24 hours before my scheduled appointment I am responsible for the full fee of my session and my account or credit or debit card or checking account will be charged for the time I have requested to be reserved for me. I understand that I may not schedule, reschedule, or cancel appointments for other adults.
Your counseling membership may be canceled at any time. Memberships are non-refundable. Accumulated session credits on your account are non-refundable and will expire 12 months from the time of your cancellation. You may continue to use accumulated session credits after membership cancellation and prior to their expiration. You may cancel your membership by completing the membership cancellation form: https://mycounselor.online/membership-cancellation-form/. If you have trouble with the online form, please contact us by calling 855-593-4357.
Mental Health Coaching memberships may not be cancelled and require a 12 week commitment. Memberships are non-refundable. Accumulated session credits on your account are non-refundable and will expire 12 months from the start date of your Mental Health Coaching membership.
If for any reason your first counselor match does not feel right for you, we will match and schedule you, at no additional cost, with a different counselor. If after your second match it still doesn’t feel right for you, we’ll refund 100% of your money. Simple as that.
To qualify for a Risk-Free Guarantee refund you must attend your "Right for You" first session(s). If you do not attend your scheduled session, you do not qualify for a refund. Refunds are only available following your attended session. If you do not request a risk-free guarantee refund following your first session, completing a second session with the counselor you matched with, you are no longer eligible for a risk-free guarantee refund.
You may request a Risk-Free Guarantee refund by contacting Member Support at receptionist@mycounselor.online within 4 weeks following the completion of your first meeting with a counselor and prior to a second meeting with a counselor and/or the end of your first billing cycle.
During the course of your membership, you may experience one or more planned price increases that happen by a predictable schedule.
The first is specific to the counselor you work with and is based on the accumulation of training and experience that results in an advancement of your counselor's status and fee. As counselors advance they and their family are rewarded for their hard work with an increase in pay that comes from an increase in their counseling fees. As of 2023 MyCounselor.Online has 3 levels of credential for our counselors, Resident, Certified, and Advanced Practice.
If your counselor is a Resident or Certified level counselor they may advance in level during the course of your work together. If this happens you will be given at least a 90 day notice before the change and will have three (3) options: 1) you can change your membership to match your counselor's new level and continue your work with the counselor, 2) you may choose a new counselor at your current membership level and remain at your membership level, 3) you may cancel your membership and discontinue services.
The second kind of planned price increase you may experience during your membership is an inflation & cost of living increase. These increases happen every 2-3 years and usually range between 10-15% across all levels of membership to adjust for increases in the cost of doing business and cost of living for our employees over time. Inflation & cost of living increases generally go into effect at the beginning of a calendar year. The last increase of this kind went into effect in January of 2023 and the next planned increase is scheduled for January 2025. Your membership fees will not increase until after you have completed at least 1 year of membership at the price you began your membership at. Upon the annual anniversary of your membership, your membership fee will adjust to the then-current membership rate.
To set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. The services MyCounselor.Online provides are religious-based counseling which may or may not be covered by health insurance. If it is permitted under your health insurance policy, your insurance may provide some coverage for the treatment you receive.
MyCounselor.Online is not in-network with any insurance provider, does not accept consignment of medical benefits, and does not bill insurance for services provided.
That being said, counseling is a covered benefit under many insurance plans and some clients have received out-of-network benefits for our services. Some networks, recognizing our excellence in certain specialized areas, have agreed to reimburse our clients at in-network levels even though we are not on their in-network panels. This is solely at the discretion of your insurance provider. Services offered through us are generally not covered by Medicare or Medicaid.
At this time we do not offer any service that submits for reimbursement to insurance on your behalf. If you would like information to be added to your sales receipts in order to self-submit to your insurance for possible reimbursement, please email accounting@mycounselor.online.
An electronic or phone session is defined as a counseling session conducted via internet video/audio conferencing or telephone. Advancements in technology have enabled the use of video counseling sessions that are very near an in-person experience. However, technology does not always cooperate. If an electronic session is scheduled and there is a technical difficulty where a video session is not possible, a phone session will be provided as an equivalent service.
*We cannot provide services if doing so could pose a danger to yourself or others, such as when you are operating a vehicle. You are responsible to be in a safe situation when you join your therapy session. If you are not in a safe situation at the time of your appointment you are still financially responsible for the time reserved.
MyCounselor.Online is committed to helping all who come to us, regardless of age, sex, race, ethnicity or religious affiliation. We understand there are areas of counseling that are out of our expertise. In such cases, we seek to assist clients in locating the appropriate resources. MyCounselor.Online is a Christian organization and the services we offer are centered on Christian values. Even though we do not seek to impose personal values on the client, we do consider the spiritual along with the physical, social, and psychological aspects of the person.
Please be informed that any sexual contact between client and counselor of any kind is strictly unethical and is not a part of any recognized therapy. Sexual intimacy, including intercourse, fondling or seductive language, is not allowed and should be reported.
You can find a directory of counselor contact information on our website here: https://mycounselor.online/contact/
Your counselor may not be immediately available by telephone. While he or she may be in their office, they probably will not answer the phone when with a client. For non-emergency services please call our office at 855-593-4357. When we are unavailable, our telephone is answered by an answering service voice mail that we monitor frequently. We will make every effort to return your call on the same day you make it. If you are difficult to reach, please inform us of sometimes when you will be available.
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 and ask for the psychologist or psychiatrist on call. You may also contact the Emergency Hotline 24 hours a day by calling: 1-800-494-7355. If you are experiencing a life-threatening emergency, please call 911 or go to the nearest hospital emergency room.
If your counselor will be unavailable for an extended time, he or she will provide you with the name of a colleague to contact, if necessary.
Unless you grant us written permission we will neither inform anyone that you are receiving counseling, nor will we disclose the content of counseling sessions.
However, there are some limits to confidentiality. These situations rarely occur in our practice, but if a similar situation occurs, your counselor will make every effort to fully discuss it with you before taking any action. The confidentiality must be broken if one or more of the following applies:
While MCO is committed to maintaining the privacy and confidentiality of all communications between you and your therapist, it is important to know that the confidentiality of communication through electronic means such as: telephone, cell phone, e-mail, chat, or other electronic means cannot be guaranteed.
Your counselor may occasionally find it helpful to consult other professionals about a case. During a consultation, every effort is made to avoid revealing the identity of our clients. The consultant is also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless your counselor feels that it is important to your work together.
If your therapist is pursuing state licensure, he or she may share the content of your session with his or her supervisor who is legally bound to the above-referenced limits of confidentiality.
MyCounselor.Online is committed to providing the highest quality mental health and personal development counseling services possible. To ensure the quality of the services you receive and to facilitate the training of our counselors MyCounselor.Online may tape or record counseling sessions. This may include audio, video, and/ or live supervision. The signing of this counseling services agreement constitutes a release of liability and written permission to record your sessions for quality assurance and training purposes. A few things you should know regarding the recording of sessions are:
Any concerns you may have regarding the recording process can be addressed at any time with your counselor or you may contact MyCounselor.Online at 855.593.4357 regarding this matter.
If you do not wish to have your counseling services recorded MCO may refer you to other counseling resources in the community where your counseling needs can be met without the recording of your sessions.
As a minor, when you meet with a counselor you and your parents will discuss the challenges you are facing in your life. Your counselor will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to your counselor about the issues that are bothering you.
Sometimes these issues will include things you don't want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling.
As a general rule, your counselor will keep the information you share with them in your sessions confidential, unless they have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with your counselor in a counseling session. In some situations, your counselor is required by law or by the guidelines of their profession to disclose information whether or not they have your permission. Some of these situations are listed below.
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your counseling records. It is MyCounselor.Onlines’s policy to request an agreement from parents that they agree to give up access to your records. If they agree, your counselor will provide them only with general information about your work together, unless he or she feels there is a high risk that you will seriously harm yourself or someone else. In this case, your counselor will notify them of his or her concern.
Furthermore, if you are involved in a court case and a request is made for information about your counseling or therapy your counselor will not disclose information without your written agreement unless the court requires them to. Your counselor will do all they can within the law to protect your confidentiality, and if they are required to disclose information to the court, they will inform you that this is happening.
Except for situations such as those mentioned above, your counselor will not tell your parent or guardian specific things you share with them in your private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of or would be upset by but that do not put you at risk of serious and immediate harm.
However, if your risk-taking behavior becomes more serious, then your counselor will need to use their professional judgment to decide whether you are in serious and immediate danger of being harmed. If your counselor feels that you are in such danger, they will communicate this information to your parent or guardian. Your counselor may also provide them with a summary of your treatment when it is complete. Before giving them any information, your counselor will discuss the matter with you, if possible, and do his or her best to handle any objections you may have with what your counselor is prepared to discuss.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have with your counselor at your next meeting. Your counselor will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and we are not attorneys.
Minors must be accompanied by a parent or guardian to their first appointment.
Relationship counseling works best when the focus of our work is on your relationship. When working with you, it is expressly understood that our client is both your relationship and each of you as individuals. To maintain fidelity to both of you and to your relationship, we ask for your consent on the following agreements.
When a couple enters into counseling, it is considered to be one unit. This means that our allegiance is to the couple “unit,” and not to either partner as individuals. We find this is particularly important in creating a space where both partners can feel safe. Therefore, we adhere to a strict “No Secrets” policy. This means that we will not hold secrets for either partner. This policy is intended to allow us to continue to treat the couple by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated.
On occasion during the counseling process, individual partners may be seen for an individual counseling session. In this case, the individual session is still considered as part of the couple’s counseling relationship. Information disclosed during individual sessions may be relevant or even essential to the proper treatment of the couple. If an individual chooses to share such information with their counselor, we will offer the individual every opportunity to disclose the relevant information and will provide guidance in this process. If the individual refuses to disclose this information within the couple’s session, we may determine that it is necessary to discontinue the counseling relationship with the couple. If there is information that an individual desires to address within a context of individual confidentiality, we will be happy to provide referrals to therapists who can provide concurrent individual therapy. This policy is intended to maintain the integrity of the couples/marital counseling relationship.
It is understood that the purpose of marital/couples therapy is for the amelioration of distress within a relationship. Therefore, if both partners request our services as counselors, they are expected not to use the information given to us during the therapy process against the other party in a judicial setting of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena our testimony or records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case.
Both partners must provide their consent to release marital/couples counseling records. If one partner does not provide consent, records will not be released.
The promise of confidentiality helps to maintain emotional safety in group therapy. Group facilitator(s) are bound to maintain confidentiality and group members are bound by honor to keep what is said in the group confidential. It is recognize that group members may want to share what they are learning in group with family and friends outside of group. A member may share one’s own experience in terms of skills learned and realizations made, as long as all information regarding other group members is kept private and confidential.
While MyCounselor.Online is a provider of religious-based counseling and thus is not subject to HIPAA, we believe the standards of practice established by HIPAA are important to quality client care. We, therefore, choose to operate in accordance with HIPAA standards.
This notice describes how personal information about you may be used and disclosed and how you can get access to this information in accordance with HIPAA standards. Please review it carefully.
MyCounselor.Online (MCO) may use or disclose your protected health information (PHI) for treatment, payment, and health care operations for the purposes within your written authorization. To help clarify these terms, here are some definitions:
The HIPAA Privacy Rule allows MyCounselor.Online providers and staff to communicate with clients regarding their health care whether through email, by phone, or in some other manner. In addition, the Rule does not prohibit MCO providers and staff from leaving messages for patients on their answering machines.
By signing this document, you are authorizing MCO to leave messages that contain protected health information (PHI). Messages that contain PHI may include appointment information, payment information and treatment plans. The goal of this authorization is to decrease the call volume and delay in communication between patients, staff and providers. However, to reasonably safeguard patient privacy, MCO providers and staff may limit the amount of information disclosed on the answering machine.
This authorization is in effect until cancelled in writing.
MCO may disclose PHI for purposes outside of regular treatment, payment, or health care operation only when you sign a specific authorization for that purpose. An “authorization” is written permission above and beyond the general consent that permits the normal PHI disclosures. An example would be if an attorney or one of your family members wanted to know about your treatment. In those instances, your MCO counselor would obtain written authorization from you before releasing this information.
PHI normally includes information such as the date and time of a session, the type of session (individual, couples, testing, etc.), fee, diagnosis codes, basic treatment plan, and your counselor’s name, credentials and signature. “Psychotherapy Notes” are more detailed and sensitive notes made about your conversations during a counseling session which your counselor has kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. MCO will need to obtain signed authorization from you before releasing these notes.
You may revoke all such authorizations of PHI or psychotherapy notes at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) MCO has relied on that authorization and already followed through on the action you authorized; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
MCO may use or disclose PHI without your consent or authorization in the following circumstances:
Right to request restrictions. You have the right to request restrictions on certain uses and disclosures of PHI. However, MCO is not required to agree to a restriction you request.
Right to receive confidential communications by alternative means and at alternative locations. You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a counselor at MCO. On your written request, MCO will send your bills to another address.
Right to inspect and copy. You have the right to look at and/or obtain a copy of PHI and psychotherapy notes in the mental health and billing records used to make decision about you for as long as PHI is maintained in the record. MCO may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, MCO will discuss with you the details of the request and denial process. If you desire copies, we will charge a fee for costs associated with our request including the cost of copies, mailing or other supplies in accordance with Federal and/or State regulations.
Right to amend. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. MCO may deny your request. On your request, MCO will discuss with you the details of the amendment process.
Right to accounting. You generally have the right to receive an accounting of the disclosures of PHI. On your request, MCO will discuss with you the details of the accounting process.
Right to a paper copy. You have a right to obtain a paper copy of this notice upon request, even if you have agreed to receive this notice electronically.
Duty. In the case of marital counseling, it is the position of MCO that therapists not engage in the withholding of information vital to the relationship from spouses. Specifically, infidelity, criminal acts, and behaviors of a spouse which place the other spouse at risk of physical or emotional damage will not be kept private. Instead, your therapist will work with you on a plan of disclosing this information to your spouse as a part of a couple’s session set at the soonest possible date.
If you are concerned that MCO has violated your privacy rights, or you disagree with a decision made about your access to records, you may contact our CEO, Josh Spurlock, at 720-306-8992.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Information about filing such a complaint can be found online at: https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html or the person listed above can provide you with the appropriate address upon request. Please note that you will not receive retaliation for filing a complaint with either MCO or the U.S. Department of Health and Human Services.
This policy went into effect on July 16, 2022. MCO reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that MCO maintains. MCO will provide you with a revised notice at the time of your next visit to our facilities or by mail.
The Telephone Consumer Protection Act requires client consent to opt-in to receiving SMS text messages. By signing this document, you authorize MyCounselor.Online to text appointment reminders to the number(s) you provide. You are responsible for any carrier fees associated with receiving texts. You may opt-out of text reminders at any time by replying “STOP” to the automated message or by contacting our office in writing.
The MyCounselor.Online website Privacy Policy and Terms of Service are incorporated in this informed consent document by reference, you are affirming your agreement to both by receiving services from MyCounselor.Online.
When you have read this document please electronically sign it below. Your signature indicates you have read and understood the conditions as read and agree to receive services under these conditions.
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Document Name: Informed Consent Document (ICD) v.01-03-24
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