Informed Consent

This informed consent and agreement are entered into by and between Piper Harris “Counselor,” of Untangled Mind, LLC and ______________________“Client (s)” whereby Counselor agrees to provide Counseling Services for Client (s) with a client-led focus. Client(s) will receive counseling sessions with this agreement to begin the signing of this agreement.

The Process of Counseling: I am a master’s level clinician, awaiting associate professional counseling (APC) pre-licensure in 2023. As a Counselor, I will participate in a 2-year, 3,000-hour residency. After the residency, Counselor will receive LPC, a licensed professional counselor in the state of Georgia. Currently, the Counselor is under direct clinical and site supervision by Dr. Susan Belangee, Georgia license LPC7099. Issues and concerns should be addressed with Counselor; however, Dr. Belangee may also be contacted (please request contact information).

Core Values and Statement of Faith: I am committed to honoring Jesus Christ and glorifying God, remaining flexible and responsive to the Holy Spirit in all that I am called to be and do. I am committed to Biblical truths and to excellence and unity in the delivery of my services. I acknowledge the complexity of humans as physical, social, psychological, and spiritual beings. The ultimate goal of counseling under the direction of my Christian Faith is to help others move to personal wholeness, interpersonal competence, mental stability, and spiritual maturity. Some interventions may include Christian components; however, I respect your autonomy in choosing whether to participate or not and am sensitive to your wishes.

Counseling Practice: Currently, the Counselor serves adults 21 years and older and couples. This may change at any time per the Counselor’s discretion. Counseling is a partnership (defined as an alliance, not a legal business partnership) between the Counselor and the Client(s) in a thought-provoking and creative process that inspires the client(s) to maximize personal and professional potential. It is designed to facilitate the creation/development of mental health personal, professional, or business goals and develop and carry out a strategy/plan to achieve those goals. Counseling is not always comfortable or straightforward, as difficult emotions often must be sorted through for change to occur. Clients should feel comfortable with me as their counselor and be able to ask about whatever is on their minds regarding the process.

Risks and Benefits: Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, because the process of counseling often requires discussing the unpleasant aspects of your thoughts and choices. However, counseling has been shown to benefit individuals undertaking it. Benefits can include: counseling often leads to a significant reduction in feelings of distress, increased satisfaction in inter and intra-personal relationships, greater personal awareness and insight, increased skills for managing stress and situations and life events, and resolutions to specific problems and actualization of goals. There are no guarantees about what will happen. Counseling requires a very active effort on your part. To be most successful, you will have to work on things we discuss outside of sessions. The Client(s) understands that to enhance the counseling relationship, the Client(s) agrees to communicate honestly, be open to feedback and assistance, and create the time and energy to participate fully in their sessions, both in and outside of the therapy room. The Client(s) agrees it is their responsibility to maintain engagement in their counseling; the Counselor will not remind the Client(s) to follow up on session reservations, activities, assignments, or assessments which need to be completed. The Client(s) recognizes this is a commitment of their time and should allocate the hours required to grow in their personal development.

1) Counselor-Client Relationship
A. Counselor agrees to maintain the ethics and standards of behavior established by the American Association of Christian Counselors (AACC) https://www.aacc.net/about/. It is recommended that the Client(s) review the Code of Ethics and the applicable standards of behavior. Additionally, the Counselor adheres to the State of Georgia standards and laws for counselors, https://rules.sos.ga.gov/GAC/135-7

B. Dual Relationships: Exist when a Counselor interacts with a client(s) in any capacity beyond a Counselor’’s role, such as being the client’s friend, business associate, or teacher of the client’s child. As your Counselor, I will not accept you as a client(s) if I feel a significant dual relationship exists. It is essential to realize that not all dual relationships are unethical or avoidable. Counseling never involves any dual relationship that impairs the Counselor’s objectivity, or judgment, or that can be exploitative. In some areas, dual relationships may be unavoidable. As your Counselor, I will never publicly acknowledge working with you without your permission; in most cases, I will allow you to approach me if you choose to do so. It is your responsibility to advise me if a dual relationship exists or arises that may become uncomfortable for you in any way. I will always listen and respond to your feedback and will discontinue the dual relationship if I find it is interfering with, or may interfere, with, the effectiveness of our counseling or your welfare. It is important to remember that you are experiencing me only in a professional role. Please understand that invitations to social gatherings or gifts may or may not be accepted. This is not because I do not care for you; it is based purely on ethical standards to provide you with the very best in counseling services.

C. Social networking and Internet Searches: as your Counselor, I will not accept friend requests from current or former clients on social networking sites. That would violate professional standards of ethical behavior and potentially compromise your confidentiality. As a Counselor and business owner, I do maintain a social media presence but will not imply, infer, or recognize you as a past or present client(s) on social media postings and responses. As your Counselor, I request that clients not communicate via social networking websites.

D. Counseling Plan: The Client is solely responsible for creating and implementing their own physical, mental, and emotional well-being, decisions, choices, actions, and results arising out of or resulting from the counseling relationship and his/her counseling sessions and interactions with the Counselor. The Counselor cannot guarantee any unlimited positive outcomes for the Client(s). As such, the Client(s) agrees that the Counselor is not and will not be liable or responsible for any actions or inaction or for any direct or indirect result of any services provided by the Counselor. At any point, the Counselor may refer you to a professional that may provide these services. If you are currently receiving treatment from a licensed mental health professional, you must inform them of our work together; a form will be provided to you.

E. Termination: Client(s) further acknowledges they may terminate or discontinue the counseling relationship at any time. The Client(s) also acknowledges that the Counselor may terminate the counseling relationship at any time due to inappropriate, abusive behavior, including cursing, degrading, or attacking the Counselor. The Client(s) also acknowledges that the Counselor may terminate the agreement due to repeated absences, owed debt, or any other concerns for ethical boundaries related to the AACC code of ethics.

F. Appointments: Sessions are 45-50 minutes in duration, once per week at a time agreed upon. The Counselor is located in the Eastern Time Zone and solely offers counseling in the state of Georgia. The time scheduled for your session is assigned to you and you alone. You will be given access to a client portal that allows for payment and scheduling.Alerts and reminders are sent to clients, however, the client is solely responsible for their session times.

Cancellation: Client(s) agrees to the following cancellation policy. Cancellation of any sessions must be received within 24 hours of scheduled services. Client(s) agrees to a timely appearance at all sessions. If the client(s) is unable to arrive within 15 minutes past the session's beginning time, the client(s) will be charged their session and/or fee. If the Counselor cannot make the session, Client(s) will be notified before the scheduled appointment. If, for some reason, the Client(s) is unable to find a session date and time that works for their schedule, the Client(s) may email the Counselor and request additional dates and times. This request is not a promise of the requested counseling session time/date.

G. Professional Fees
All counseling fees are to be paid when services are rendered. The standard fee for the initial intake is $150.00, and each following session is $100-$120. You are responsible for paying when your fees are due unless prior arrangements have been made. Payments must be made by credit card via the client portal. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

Payment: Client(s) agrees to the contract terms and will notify the Counselor if payment type changes. If payments are declined, the Client(s) will be asked for an additional payment form; however, if a different form of payment is not received, a fee of $25.00 will be assessed for every declined credit card. Any delinquent payments exceeding 30 days after the payment due date will suspend all counseling sessions and services. If Client(s) does not maintain payment on the due date or leaves counseling without notice and completion of contract terms, the client(s) will be placed into remediation in a small claims court and agrees to pay all legal fees incurred for Client(s) and Counselor.

Other Fees: Other fees will be assessed for requested extended phone conversations or emails. The fee schedule below addresses all fees.

Type of Service

Assigned Fee

Notes

Initial Intake

$150.00

45-50 minutes for the first session

Individual Session

$100.00-$120

45-50-minute sessions

Couples Session

$100-$120

45-50-minute sessions

Missed Session without 24 Hour Notice-Full Session Fee

This fee is applied when 24 hours notice is not provided and the counselor and client have not made other arrangement

Declined Debit/Credit Cards

$25.00

This is applied to ALL declined debit/credit cards.

Extensive Email Response

$10.00 per email

This rate applies to length emails sent in response to yours. However, this shall not be used as an extension of sessions on a regular basis.

Extensive Phone Conversations

$1.00 per minute

This fee is applied if we are unable to speak for less than 10 minutes no more than 20 minutes regarding scheduling or other concerns.

Consultation Appointment

$150

This includes speaking engagements, business planning, etc.

Raising of fees: Fees will be re-evaluated each calendar year. If yearly evaluations reflect a fee increase, current clients may fulfill their current contract terms. However, subsequent contract terms will reflect a fee increase. Previous contract terms do not guarantee fees indefinitely.

G2. Good Faith Estimate
Shows the costs of items and services that are reasonably expected for your health care needs for an item or service, mental health counseling. The estimate is based on information known when the estimate was created and does not include any unknown or unexpected costs that may arise during treatment.

Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment and the accompanying cost changes.

You may contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

H. Professional Records
The Counselor is required by the AACC to keep appropriate records of the counseling services I provide. Your records are maintained securely on a HIPPA-secured platform. All other information is saved on an external drive with encryption and password protection. Brief records noting that you were here, your reasons for seeking counseling, the goals, and progress we set, topics we discuss, your medical and social history, income records, payment service records, records may have received from other providers you have given to Counselor with your written permission, as well as billing records or other communications between Counselor and Client including; email, text, or e-sign services. Any records will be retained for no less than seven years. Please see confidentiality below for agreement on professional records and how they may be acquired outside of the Counselor.

I. Confidentiality: This counseling relationship, as well as all information (documented or verbal) that the Client(s) shares with the Counselor as part of this relationship, is bound by the principles of confidentiality outlined in the Code of Ethics. It is important that you understand all identifying information is kept confidential, except as those listed below.

Limits of Confidentiality: It is important that you understand the limits of confidentiality. In certain situations, the Counselor may be required by law to reveal information obtained during sessions to outside persons or agencies without your permission. This includes the following:

Confidentiality does not apply to generally known to the public or the client’s industry.
Confidentiality does not apply to information obtained by a third party without breach to the client.
Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly.
Confidentiality does not apply to cases of potential harm to self or others.
Confidentiality does not apply to cases of illegal activity.
Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship.
Confidentiality may not apply to group or marriage counseling clients; secrets will not be maintained by the Counselor for marriage or group members' purposes.
Counselor may disclose confidential information in proceedings brought by Client against a Counselor.
Counselor may disclose independently developed information using only reference to general techniques and practice on social media, website, or podcast. No identifiable information will be revealed outside of gender and general techniques and behaviors.

Release of Information for accreditation, continuing education credits
The Counselor requires logs to show the engagement of client hours to maintain Counselor residency with the state of Georgia. Information provided to the state does not include PHI.

J. Contacting me & Hours of Operation
I am often not immediately available by phone or email. I do not answer my phone or email when I am with clients or otherwise unavailable. At these times, you may leave me a message or email. However, this is not confidential. I will return your phone call or email in no less than 24 hours on weekdays. If you have an emergency, you must call 911 and speak with professionals on the call. I will make every attempt to inform you of planned absences.

Hours of Operation

Counselor will be available to Client(s) Monday through Thursday from 10 AM to 6 PM Eastern Standard Time and Friday from 10A-2P. If communication is received after 6 PM EST, the Counselor will respond the following business day. If communication is received after 2 PM EST on Friday, the Client(s) will receive communication the following Monday.

Contact
Phone: (770) 317-1126

Email: piper@untangledmind.net

Limited Liability, Assumption of Risk, Release

Except as expressly provided in this Agreement, the Counselor makes no guarantees, representations, or warranties of any kind or nature, express or implied, concerning the counseling services negotiated, agreed upon, and rendered. In no event shall the Counselor be liable to the Client(s) for any indirect, consequential, or special damages. Notwithstanding any damages that the Client(s) may incur, the Counselor's entire liability under this Agreement and the Client’s exclusive remedy shall be limited to the amount actually paid (not applicable) by the Client(s) to the Counselor under this Agreement for all counseling services rendered through and including the termination date.

You agree that if you engage in any counseling in person or virtually, seeking personal, professional advancement, and/or behavioral change, or enter our premises or use any facility or equipment on our premises for any purpose or any online tools associated with counseling, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical, mental, or emotional acts. This includes injury or damage sustained while and/or resulting from counseling sessions, using online tools, workbooks, guided exercises, any premises or facility, or using any equipment, whether provided to you by Counselor or otherwise, including injuries or damages arising out of the negligence of Counselor, whether active or passive, or any of Counselor’s affiliates, employees, agents, representatives, successors, and assigns. You assume the risk of your participation in any counseling session, activity, class, program, instruction, event, or counseling.

You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury mentally, physically, or emotionally, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Counselor or otherwise.

You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Piper Harris of Untangled Mind, LLC, owner, staff, and Counselor (and Counselor’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Counselor, whether active or passive, or any of Counselor’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability include, without limitation, injuries that may occur as a result of (a) negligent instruction or counseling (b) negligent hiring or retention of employees, and/or (c) emotional, mental, or physical pain resulting from Counselor’s or anyone else’s negligence.

3) Entire Agreement This document reflects the entire agreement between the Counselor and the Client(s) and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered, or supplemented except in writing, signed by both the Counselor and the Client(s). By execution of this agreement, you hereby agree to indemnify and hold harmless Counselor from any loss, liability, damage, or cost Counselor may incur due to the provision of counseling by Counselor to you. Dispute Resolution If a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client(s) and Counselor agree to attempt to mediate in good faith for up to 30 days after the notice is given. If the dispute is not resolved, and in the event of legal action, the client(s) will incur all attorney’s fees and court costs for all parties.
Severability If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If the Court finds that any provision of this Agreement is invalid or unenforceable but that by limiting such provision, it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.
Waiver The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Agreement.
Applicable Law This Agreement shall be governed and construed in accordance with the laws of the State of Georgia, without giving effect to any conflicts of laws provisions.

Binding Effect This Agreement shall be binding upon the parties hereto and their respective successors and permitted assigns. Please see the acknowledgments below.

Consent/Acknowledgements You expressly agree that the foregoing informed consent, contract terms, assumption of risk, and indemnity agreement is intended to be as broad and inclusive as permitted by the law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. You acknowledge that Counselor offers a service to his/her client(s), encompassing the entire mental, emotional, and physical spectrum. This release is not intended as an attempted release of claims of gross negligence or intentional acts. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk, and indemnity agreement. You are aware and agree that by executing this contract, waiver, and release, you are giving up your right to bring legal action or assert a claim against Counselor for Counselor’s negligence or for any defective product or service used while receiving counseling from Counselor. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made. You voluntarily agree if the agreement is completed online, your agreement and acknowledgment of this waiver and release are agreed upon through your receipt of this agreement.

GFE