Informed Consent

2026 UM Informed Consent & Agreement

INFORMED CONSENT & AGREEMENT

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: Piper Harris is an licensed professional counselor with Georgia State (LPC016231 ). NPI number 1417661307. The Counselor currently serves adults; this may change at any time at the Counselor’s discretion.

Counseling is a partnership; defined as a therapeutic alliance, not a legal business partnership, between the Counselor and the Client in a thought-provoking, structured, and growth-oriented process that supports clients in maximizing personal and professional potential. Counseling helps identify and develop personal and psychological goals and the strategies required to achieve them.

Therapeutic work is not always comfortable or linear. Difficult emotions often need to be examined and processed for meaningful change to occur. Clients are encouraged to communicate openly and to ask questions about any aspect of the counseling process. Feeling comfortable with the Counselor and the structure of treatment is essential for effective work together.

Core Values and Statement of Faith: Piper Harris is committed to honoring Jesus Christ and glorifying God, remaining flexible and responsive to the Holy Spirit in all she is called to be and do. Her work is grounded in Biblical truth and in excellence, integrity, and unity in the delivery of all services. She recognizes the complexity of human beings as physical, social, psychological, and spiritual, and she approaches counseling through this integrated understanding.

The ultimate aim of counseling informed by her conservative Catholic Christian faith is to support clients in moving toward personal wholeness, interpersonal competence, mental stability, and spiritual maturity. Some interventions may include Christian components; however, client autonomy is fully respected, and clients may choose whether or not to participate in faith-based elements.

As a practicing conservative Catholic Christian, Piper’s faith informs her worldview and guides every aspect of her life, including her professional work in counseling and consultation. She is committed to serving all clients with respect, compassion, and professional excellence while upholding the principles of her faith.

Untangled Mind, LLC will not tolerate purposeful attempts to use counseling or consultation services to undermine, disparage, or coerce affirmation of beliefs contrary to Piper’s conservative Catholic Christian faith. All therapeutic interactions must occur in good faith, with mutual respect and with the genuine intent to engage in services for their intended purpose.

In alignment with the First Amendment’s protections of religious freedom and free speech, Piper Harris stands firmly by her right to live and practice according to her faith and equally respects the rights of clients to hold their own beliefs. She asks for the same courtesy in return.

By engaging in counseling services, clients acknowledge their understanding of this foundational aspect of the practice and their agreement to maintain a respectful, professional therapeutic environment. Untangled Mind, LLC welcomes individuals of all faiths and belief systems, provided their intention is to seek services aligned with the practice’s core focus on anxiety and trauma counseling and to engage respectfully throughout treatment. Rights to Terminate: The Counselor may terminate counseling if a client engages in behavior that is hostile, harassing, manipulative, or intentionally directed at challenging or undermining the Counselor’s conservative Catholic Christian faith. Such conduct violates professional boundaries and interferes with the ability to provide effective treatment. In such cases, the Counselor will provide referrals to alternative providers.

Iatrogenic Statement and Counseling Risks and Benefits

Iatrogenic Statement

While our counseling practice is dedicated to providing the highest quality care and support to our clients, it is important to acknowledge the possibility of unintentional harm. Therapy and counseling are complex processes, and despite our best efforts, some interventions may lead to unforeseen negative effects. Adverse events may occur during or shortly after treatment, potentially leading to a deterioration of mental state, damaged interactions between the client and counselor, and ruptures in the therapeutic alliance. The use of inappropriate methods may also lead to a rupture of the relationship, increasing the risk of iatrogenesis or adverse psychological or behavioral effects. A poor fit between the counselor and client, as well as risks attached to specific interventions, can further contribute to these negative outcomes.

We strive to minimize these risks by continuously monitoring and evaluating our practices. We encourage open communication with our clients to address any concerns or adverse experiences promptly. Your well-being is our utmost priority, and we strive to create a safe and supportive environment for your therapeutic journey.

Risks and Benefits

Risks:

- Emotional Discomfort: Counseling may involve experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, as it often requires discussing unpleasant aspects of your thoughts and choices.

- Adverse Events: These may occur during or shortly after treatment, leading to potential deterioration of mental state.

- Therapeutic Ruptures: Damaged interactions between the client and counselor, and ruptures in the therapeutic alliance, may happen.

- Inappropriate Methods: The use of inappropriate therapeutic methods can lead to a rupture of the relationship and an increased risk of iatrogenesis or adverse psychological or behavioral effects.

- Poor Fit: A poor fit between the counselor and client can contribute to negative outcomes.

- Intervention Risks: Specific interventions may carry inherent risks that could impact the therapeutic process and outcomes.

Benefits:

- Counseling has been shown to benefit individuals undertaking it. Potential benefits include: Significant reduction in feelings of distress

-Increased satisfaction in interpersonal and intrapersonal relationships

-Greater personal awareness and insight

-Enhanced skills for managing stress and situations

-Resolutions to specific problems

-Actualization of personal goals

No Guarantees: There are no guarantees about what will happen during counseling. Success in counseling requires a very active effort on your part. Counseling provides tools and relief, but is not a cure. To be most successful, you are expected to follow through on tools and other items discussed in sessions outside of those sessions.

Client Responsibilities:

To enhance the counseling relationship, the Client(s) agrees to:

-Communicate honestly

-Be open to feedback and assistance

-Create the time and energy to participate fully in their sessions, both in and outside of the therapy room

-Maintain engagement in their counseling without relying on reminders from the app

-Counselor for follow-up on session reservations, activities, assignments, or assessments.

- The Client(s) recognizes that counseling is a commitment of their time and should allocate the hours required to grow in their personal development.

Counselor Responsibilities:

- Continued Assessment: Regularly assess the client's progress with appropriate tools and techniques to ensure the effectiveness of the treatment.

- Ongoing Discussion: Maintain open communication with the client regarding the course of treatment and goal actualization.

- Tailored Interventions: Use evidence-based and individualized therapeutic interventions suited to the client's unique needs and circumstances.

- Professional Development: Engage in ongoing professional development to stay current with the latest counseling practices and research.

- Ethical Standards: Adhere to the ethical guidelines and standards set forth by professional organizations and regulatory bodies.

- Safety and Confidentiality: Ensure the safety and confidentiality of the clientʼs information and therapeutic process.

- Feedback and Adjustment: Seek regular feedback from the client and be willing to adjust the treatment plan as needed to meet their needs better.

- Supportive Environment: Create a supportive and non-judgmental environment that fosters trust and openness.

Counselor-Client Relationship

Ethical Standards:

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

-Ethical concerns are encouraged to be discussed with Piper Harris, however, if the client is not comfortable they may file at complaint at https://sos.ga.gov/licensing-division-complaints.

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/. (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 (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 Counselorʼs role, such as being the clientʼs friend, business associate, or teacher of the clientʼs 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 Counselorʼs 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 best 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.

Telehealth/Telemedicine: Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Georgia. Under the Georgia Telemental Health Ruling, telemedicine is broadly defined as delivery of services by a licensed Professional Counselor, Social Worker, or Marriage and Family Therapist using technology-assisted media. From one location to another. (1)You retain the option to withhold or withdraw consent at any time ensuring your review at https://rules.sos.ga.gov/gac/135-11. There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs.

 

Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

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 providing 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) acknowledge that they may terminate or discontinue the counseling relationship at any time. Client(s) further acknowledge that the Counselor may terminate the counseling relationship at any time due to inappropriate or abusive behavior, including cursing, degrading, or attacking the Counselor. The Counselor may also terminate services due to repeated absences, unpaid balances, or other concerns related to ethical or professional boundaries in accordance with the AACC Code of Ethics.

Client(s) acknowledge that counseling services are intended to address identifiable clinical needs. If, in the Counselor’s professional judgment, no current clinical need is apparent or continued treatment is no longer clinically indicated, the Counselor may recommend termination of services or referral to a more appropriate level or type of care.

Client(s) further acknowledge that termination of counseling services, when conducted in accordance with professional and legal standards, does not constitute abandonment. Under Georgia law and professional ethics, abandonment refers to the unilateral cessation of services without reasonable notice, clinical justification, or appropriate referral when a client continues to require care.

Client(s) acknowledge that expectations regarding the estimated scope, duration, and frequency of services are outlined in the Client’s individualized Treatment Plan and Good Faith Estimate (GFE). Termination of services that occurs within or consistent with those clinical estimates, or due to the absence of ongoing clinical need, does not constitute abandonment. When clinically indicated, the Counselor will provide reasonable notice and referral options to support continuity of care.

F. Appointments: Sessions are 45-50 minutes in duration 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: Missed Appointments and Late Cancellations

If you cancel an appointment with less than 24 hours’ notice or fail to attend a scheduled session, you will be charged the full session fee. This policy applies without exception. 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 attend the session, the 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. All clients are required to enroll in autopay; session fees will be automatically charged either at the time of service or prior to the session for clients with repeated late payments.The standard fee for the initial intake session including workbook and monthly reassessment is $350. Each individual session thereafter is $175 unless otherwise negotiated. To maintain accurate monthly assessments and continuity of care, clients must schedule no fewer than two sessions every 28 days. This frequency ensures that reassessment data remains clinically relevant and that progress can be accurately tracked. After six months and/or 18 sessions, the counselor will evaluate the necessity of continued monthly reassessments. At that time, reassessments may be reduced or discontinued based on clinical judgment and the client’s treatment needs. Returning to Care: Clients who have not attended a session within a 6-month period will be considered inactive. If you choose to return after this window, a new intake session is required at the current intake rate. This ensures we can reassess your goals, progress, and any new needs to provide the most effective and ethical care.

Extended Sessions (75 minutes) For certain clinical presentations, such as trauma reprocessing (e.g., EMDR, Prolonged Exposure), severe anxiety, or prolonged grief, extended 75-minute sessions may be required. These sessions provide the necessary time for focused work, processing, and proper emotional regulation before closing. The fee for a 75-minute extended session is $250. Trauma Intensives The Trauma Intensive program is billed at a flat fee of $3595, which includes all preparatory work, assessment review, treatment planning, intensive sessions, and post-intensive follow-up. Payment is due in full upfront to reserve the scheduled dates. Because of the extensive preparation and time commitment, trauma intensives are non-refundable once scheduled.

Anxiety Psychoeducational Group: The open-entry Anxiety Psychoeducational Group is billed at $30 per one-hour session. A required workbook is purchased separately at approximately $25. Group fees must be paid prior to each session, and missed sessions are not refundable due to the open-group format.

Administrative, Documentation, and Legal Services Non-clinical services: Including documentation requests, records review, written summaries, coordination with third parties, or involvement in legal matters, are billed at $175 per hour, in 15-minute increments.

If services exceed 3 total hours, a flat rate applies:

• Half-Day (up to 4 hours): $700

• Full-Day (4–8 hours): $2,500

These rates apply regardless of how the time is used (e.g., court standby, attorney communication, records review, etc.). Counseling session notes are not intended for legal purposes. I do not provide expert witness services. Any legal engagement requires a separate written agreement and prepayment may be required.

Consultation Services

Non-clinical consultation services such as speaking engagements, professional collaboration, business planning, or advising are billed at the standard rate of $175 per hour, with a minimum of one hour. Time beyond the first hour is billed in 15-minute increments.

If the total consultation exceeds 3 hours:

• Half-Day Rate (up to 4 hours): $700

• Full-Day Rate (4–8 hours): $2,500

Additional Terms

Clients are responsible for paying fees at the time of service unless prior arrangements are made. All payments are processed via credit card through the secure client portal and are typically charged the evening of the session.

If the card on file is declined, a $25 insufficient-funds fee will be applied for each failed transaction attempt. Clients will be notified immediately and are expected to update payment information and resolve the balance by close of business the same day.

If payment is not received within 14 days, all counseling services will be suspended until the account is current. Repeated payment failures may result in the card being charged the morning of the session to ensure coverage for the counselor’s time.

Clients who discontinue counseling without resolving outstanding balances may be subject to collections. The client is responsible for any administrative fees associated with recovering unpaid balances.

By signing this agreement, you acknowledge financial responsibility for all services rendered and agree to these terms. Other Fees: Other fees will be assessed for requested extended phone conversations or emails. The fee schedule below addresses all fees.

Initial Intake $350 Individual Intake

Individual Session $175, 45-50-minute sessions

Missed Session without 24 Hour Notice - Full Session Fee Charged This fee is applied when 24 hours notice is not provided, and the counselor and client have not made other arrangements

Declined Debit/Credit Cards $25.00 each failed attempt. This is applied to ALL declined debit/credit cards.

Extensive Email Response $10.00 per email Rate applies to the 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.

Raising of fees: Fees for our services are subject to change without notice, and we reserve the right to discontinue or modify our services or products at any time without prior notice. If a product or service is listed at an incorrect price with incorrect information due to typographical error, Untangled Mind, LLC has the right, to the fullest extent permitted under applicable law, to refuse or cancel any services placed at the incorrect rate. Fees will be re-evaluated and may reflect a fee increase; current clients with packages purchased may fulfill their current contract terms. However, subsequent contract terms will reflect a fee increase. Previous contract terms do not guarantee fees indefinitely.

No Surprises Act/Good Faith Estimate: You are entitled to receive this Good Faith Estimate of your potential charges for psychotherapy services provided to you. While it is not possible for the Counselor to know in advance how many psychotherapy sessions may be necessary or appropriate for a given person, a form will be provided to you as an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the Counselor listed, nor does it include any services rendered to you not identified here. This good faith estimate is valid for the time stated in your form.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case and the estimated cost for those services depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations concerning your treatment, and you may discontinue treatment at any time.

The fee for a 45-minute psychotherapy visit (in person or via telehealth) is $175. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs or desires. You have a right to initiate a dispute resolution process with U.S. Department of Health and Human Services (HHS) if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). If you choose to utilize this dispute option, you must submit your claim within 120 calendar days from the date of your first bill. There is a $25 fee to utilize the HHS dispute process. If the agency reviewing your claims agrees with you, you must pay the price of the good faith estimate. If the agency disagrees with you and agrees with your healthcare provider, you will be required to pay the total amount.

You are encouraged to speak with the Counselor at any time about any questions you may have regarding your treatment plan or the information provided to you in this Good Faith Estimate. Please visit www.cms.gov/nosurprises for more information or to start your dispute claim.

Make sure to save a copy or picture of your Good Faith Estimate and the bill.

Premier Counseling Services

Untangled Mind offers a Premier Counseling model designed to deliver high-touch, results-driven therapy. This approach emphasizes data-informed care, measurable progress, and structured accountability to support optimal outcomes. The Premier Counseling model includes:

• A comprehensive initial assessment battery during intake

• A personalized treatment plan developed from assessment data

• A customized workbook tailored to the client's primary presenting concern

• Monthly reassessments to monitor progress and inform treatment adjustments

• Summary feedback provided monthly for clients maintaining at least part-time status (defined as a minimum of two sessions per month)

Premier Counseling is not a passive, open-ended talk model. Instead, it is a structured, evidence-based model designed to engage clients actively in the process of change. This service structure supports greater consistency, deeper insight, and long-term resilience.

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 HIPAA-compliant platform. All other information is stored on an encrypted, password-protected external drive. Records may include documentation of your attendance, reasons for seeking counseling, treatment goals and progress, session topics, medical and social history, income and payment records, and any documentation received from other providers that you have authorized in writing. Communication between Counselor and Client (including email, text, or e-sign services) may also be stored. Records will be retained for no less than seven years. Please see the Confidentiality section for details on how records may be released or acquired outside of the Counselor.

If you request records for any legal or attorney-related purpose, you must submit a signed Release of Information (ROI) form before any documentation will be reviewed or released. All records provided become the client’s sole responsibility upon release. The Counselor does not engage in communication with attorneys, legal representatives, or the court and does not provide expert witness services. These requests are considered outside the scope of the therapeutic relationship and are not part of clinical counseling services. As such, they are subject to non-clinical administrative fees, which are billed separately and must be paid in full before any documentation is released.

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 set forth in the Code of Ethics. It is important that you understand all identifying information is kept confidential, except as those listed below. Recording Prohibited (Privacy and Intellectual Property Protection) Georgia law allows a participant in a conversation to record with the consent of only one party; however, this practice is strictly prohibited within this office and during any professional services (in-person, phone, or telehealth). To protect your Protected Health Information (PHI) under HIPAA and to maintain the confidentiality of all clients, no audio, video, or image recording of any session, staff member, or environment associated with this practice is permitted without prior written consent from all involved.

In addition, all therapeutic materials, discussions, interventions, and educational content provided by this practice, including the Untangled Mind Pathway and related intellectual property, are the exclusive property of Untangled Mind LLC and are protected under applicable copyright and trademark law. Any recording, audio, video or reproducing these materials without authorization constitutes a violation of federal intellectual-property rights. Violation of this policy may result in the immediate termination of the session and/or discontinuation of services.

Limits of Confidentiality: It is important that you understand the limits of confidentiality. In certain situations, the Counselor may be legally required 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 clientʼs 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.

Litigation and Legal Involvement

Untangled Mind, LLC and Piper Harris do not provide legal services or expert witness testimony. Piper Harris does not consult with attorneys, write affidavits, or attend court proceedings on behalf of clients. If subpoenaed or otherwise compelled to participate in legal matters, all fees associated with time spent preparing documents, communicating with legal representatives, or appearing in court will be billed to the client at the current legal and administrative hourly rate.

Counseling session notes are clinical in nature and are not prepared with the intent of being used in legal proceedings. Any involvement required outside the scope of stated therapeutic services and treatment plan, including but not limited to documentation requests, deposition preparation, or testimony, will be billed.

If Piper Harris is subpoenaed or legally required to testify or provide records, all associated fees (including travel time and legal representation if needed) are the full financial responsibility of the Client, regardless of who issues the subpoena. Engagement in legal matters must be preceded by a separate agreement and paid in full before services are rendered.

Information provided to the state does not include PHI.

J. Contact & Hours of Operation

Piper Harris is often not immediately available by phone or email. She will not answer phone or email when with clients or otherwise unavailable. At these times, you may leave me a message or email. However, this is not confidential. She 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. She will make every attempt to inform you of planned absences.

Hours of Operation

Counselor will be available to Client(s) Monday through Friday from 10 AM to 6 PM Eastern Standard Time, Monday and Friday for administrative purposes. If communication is received after 5 PM EST, the Counselor will respond the following business day. If communication is received after 5 PM EST on Friday, the Client(s) will receive communication the following Monday.

Contact

Phone: (770) 317-1126

Email: piper@untangledmind.net

Written Acknowledgment and Consent to Counseling Informed Consent

I have reviewed this Informed Consent. I understand I have the right to request restrictions on how my information may be used or disclosed, and that Untangled Mind, LLC is not required to agree to the restrictions I request. I agree to the provided fee schedule and will maintain financial responsibility for all services relevant to me, including all related court fees, whether or not I have initiated subpoenas, records requests, or related services. I accept this agreement and consent to counseling with Piper Harris of Untangled Mind, LLC.

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 Clientʼs 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 or financial loss 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 Counselorʼs 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, financially, 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, financial 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 Counselorʼs 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 Counselorʼs 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, financial, or physical pain resulting from Counselorʼs or anyone elseʼs 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 attorneyʼs 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 remain 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 Professional Counseling Board, without giving effect to any conflicts of laws provisions.

Binding Effect 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, assumption of loss, 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 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, loss, 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 the Counselor for the Counselorʼs negligence or for any defective product or service used while receiving counseling from the 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.