Informed Consent for Online Counseling

Savage Life Solutions, LLC

Thank you for choosing Savage Life Solutions. In order to provide you consistent care and best practices carefully read and sign this agreement prior to any online services. The following information is to be completed by  the person being served or the person's authorized representative/parent. 

The purpose of this document is to inform you, the client, about many aspects of online counseling services:  the process, the counseling, the potential risks and benefits of services, safeguards against those risks, and  alternatives to online services. Please read this entire document, sign, and return. 

Possible misunderstandings: The client should be aware that misunderstandings are possible with telephone,  text-based modalities such as messaging, and real-time internet chat, because nonverbal cues are relatively  lacking. Even with video chat software, misunderstandings may occur due to connection problems causing  image delays or less than optimal image quality. Counselors are observers of human behavior and gather much  information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never  engaged in online counseling before, please have patience with the process and clarify information if you think  your counselor has not understood you well. Also, please be patient if your counselor asks for periodic  clarification. All sessions and messaging are in English. 

Turnaround time: Using asynchronous (not in "real time") communication such as email or messaging entails a  "lag" of response. The counselor will make every effort to respond to message requests within a 24 -hour  period. If the client is in a state of crisis or emergency, the counselor recommends the client contact a crisis line  or an agency local to the client. Clients may also utilize 911, 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or  hard-of hearing: 1-800-799-4TTY). 

Privacy of the counselor: Although the internet provides the appearance of anonymity and privacy in  counseling, privacy is more of an issue online than in person. Your therapist has chosen to use Counsol.com as the  software provider for web conferencing, and chat communications between the counselor and clients. The  client is responsible for securing his or her own computer hardware, internet access points, and password  security. The counselor has a right to their privacy and may wish to restrict the use of any copies or recordings  the client makes of their communications. Clients must seek the written permission of the counselor before  recording any portion of the session and/or posting any portion of said session on internet websites such as  Facebook or YouTube.  

Potential benefits: The potential benefits of receiving mental health services online include both the  circumstances in which the counselor considers online mental health services appropriate and the possible  advantages of providing those services online. For example, the potential benefits of video chat include the  convenience for clients to potentially receive counseling from anywhere once an internet signal and necessary  hardware is secured. 

Potential risks: There are various risks related to electronic provision of counseling services related to the  technology used, the distance between counselor and client, and issues related to timeliness. Potential risks  could include confidentiality being breached in transit by hackers or Internet service providers or at either end  by others with access to the client's account or computer. People accessing the internet from public locations  such as a library, computer lab, or café should consider the visibility of their screen to people around them. 

Position yourself to avoid others' ability to read your screen. Using cell phones can also be risky in that signals  are scrambled but rarely encrypted. 

Safeguards: Your counselor has selected an account with Counsol.com for video communications to allow for the  highest possible security and confidentiality of the content of your sessions. In order to benefit from these  safeguards, the client is required to register with Savagelifesolutions.com and utilize the chat and video software from the platform.  Your personal information is encrypted and stored on a secure server in compliance with HIPAA regulations.  The client is responsible for creating and using additional safeguards when the computer used to access  services may be accessed by others, such as creating passwords to use the computer, keeping their email and  chat IDs and passwords secret, and maintaining security of their wireless internet access points. The counselor  and client may also choose a password in the first session to be exchanged at the beginning of all subsequent  distance sessions in order to verify the identity of the client. Please discuss any additional concerns with your  counselor early in your first session so as to develop strategies to limit risk. 

Alternatives: Online counseling may not be appropriate for many types of clients including those who have  numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and  clients who are experiencing active manic/psychotic symptoms. An alternative to receiving mental health  services online would be receiving mental health services in person. Please feel free to request a change or  referral at any time you think a different counseling relationship would be more practical or beneficial for you. 

Proxies: The counselor requires this consent form to be signed by the legal guardian of any client seeking  services who is under the age of 18. The name and contact information of the legal guardian will be kept as part  of the client's record.  

Confidentiality of the client: Maintaining client confidentiality is extremely important to the counselor and the  counselor will take ordinary care and consideration to prevent unnecessary disclosure. Information about the  client will only be released with his or her express and written permission with the exceptions of the following  cases: 1) If the counselor believes that someone is seriously considering and likely to attempt suicide; 2) if the  counselor believes that someone intends to assault another person; 3) if the counselor believes someone is  engaging or intends to engage in behavior which will expose another person to a potentially life -threatening  communicable disease; 4) if a counselor suspects abuse, neglect, or exploitation of a minor or of an  incapacitated adult; 5) if a counselor believes that someone's mental condition leaves the person gravely  disabled. 

Records: The counselor will maintain records of online counseling and/ or consultation services. These records  can include reference notes, copies of transcripts of internet communication and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards. The client  will be asked in advance for permission before any audio or video recording would occur on the counselor's  end. 

FMLA/Medical Paperwork Requests: Savage Life Solutions, LLC and its providers do not provide assessments and paperwork for the following:

Family Medical Leave Act

Leave of Absence

Social Security Disability

Emotional Support Animal

Hormone Replacement Therapy

Custodial/Forensic Evaluation

Fitness for Duty/Return to Work

Documentation for Emotional Support Animals

Please note that this is not a complete list. If you are in need of these services, you will need to seek these specific services elsewhere, as it is outside of our scope to provide this information.

Procedures: The counselor might not immediately receive an online communication or might experience a local  backup affecting internet connectivity. If the client is in a state of crisis or emergency, the counselor  recommends contacting a crisis line or an agency local to the client. Clients may utilize the following crisis  hotlines: 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY). 

Payments: All payments will be processed through Savage Life Solutions electronically or via PayPal. Please notify your counselor if you prefer to use PayPal in order to receive proper information for payment to be made. Payment of fees is expected at the time of service and the client agrees to pay for each service at the time it is rendered. I understand I am responsible for all charges incurred and that all sessions are private pay.  Clients agree to notify their therapist at least 48 hours in advance if they are unable to keep their appointment.  You will have the opportunity for one (1) cancellation within a 6-month calendar period with NO PENALTIES.  No shows will be assessed one half the scheduled rate.

Disconnection of Services: If there is ever a disruption of services on the internet then the client will need to  contact their therapist and discuss how to proceed with the session.  

I understand that I have the freedom to choose to have counseling online by distance-counseling or  teletherapy. I understand that there are risks to teletherapy, such as failure in technology or breaches of  confidentiality. 

GOOD FAITH ESTIMATE FOR HEALTHCARE COSTS AND SERVICES

SAVAGE LIFE SOLUTIONS, LLC

Client/Patient Name: Date of Birth:      

The following is a detailed list of expected charges: 

Individual Live Chat/Messaging Sessions ($1.42 US per minute) 

30 minutes =  $42.60 

45 minutes = $63.90 

60 minutes = $85.20

Individual Video or Phone Sessions: (limited availability) 

30 minutes = $80

45 minutes = $120

60 minutes = $160

Individual Weekly Chat/Messaging Plans:

One 30 minute session + unlimited messaging and journal responses for the week = $65 

One 45 minute session + unlimited messaging and journal responses for the week = $85

One 60 minute session + unlimited messaging and journal responses for the week = $105

Unlimited messaging and journal responses only for the week with no session = $55 

Couples Live Chat/Messaging Sessions ($1.80 US per minute)

30 minutes = $54

45 minutes = $81

60 minutes = $108

Couples Video or phone sessions: (limited availability) 

60 minutes = $250

Couples Weekly Chat/Messaging Plans:

One 60 minute session + unlimited messaging and journal responses for the week = $120

Unlimited messaging and journal responses only for the week with no session = $70 

Email counseling/coaching (without a weekly plan): 2ï¿ US per word for client message and counselor response

Counseling and coaching services can also be obtained via email.  You will be billed two cents  per word for your initial message as well as the counselor 's response to each message.  

Messages regarding scheduling are not billed.

All services will be provided by:

Carrie B. Savage, LPC, LMCHC, TPMC, MAMFT, National Provider Identifier 1043720774

Services will be provided:

Savage Life Solutions, LLC - 1600 Lake Harbin Rd. #428 - Morrow, GA 30260 (via telehealth)

Phone: (404) 855-0685 - Contact: Carrie Savage - Email: savagelifesolutions@gmail.com

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.  The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. 

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed 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. 

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 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, www.cms.gov/nosurprises or call 1-800-985-3059.  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.