Step 1 of 2
INFORMATION, AUTHORIZATION & CONSENT TO TREAT
Qualifications and Credentials
Licensed Clinical Social Worker ———– GA License Date 2002, License No. 003082
Licensed Master of Social Work ———— GA License Date 1998
To verify license status ———————– http://verify.sos.ga.gov/verification/
Bachelor of Arts —————————— University of Michigan, Ann Arbor, 1986
Master of Social Work ———————– University of Michigan, Ann Arbor, 1997
More information—————————— https://melissalesterlcsw.com/
It is my belief that as people become more deeply connected to Self, they are capable of deeper connection with others and with the world around them. Through deep connection, we become more capable of creating peaceful and meaningful lives and a more peaceful and meaningful world. These are goals that may take time to achieve.
To achieve comfort in our own skin we must resolve as much trauma (small, medium or large) as reasonably possible. Because of this, I am trained in several Trauma Resolution Methods which I use frequently and very effectively in my practice. These include Meditation (Taoist) and Grounding Skills, EFT Tapping, Progressive Counting and various forms of Somatic work. We will always collaborate and develop our plan together.
Therapy work can sometimes be difficult. It can take time. But the reward is always worth it. Your relationships may shift and change along the way. You may even outgrow some of your relationships. Sources of distress may resolve and no longer be a focus for you. All of these are signs of growth, and as you grow, it is possible that others around you may also grow as well. Unfortunately, we cannot know in advance what will shift in your life, or how.
All communication with me is confidential and I will not disclose any information to anyone without your express, signed Release of Information. Exceptions to this include 1) when/if in my professional judgment you pose a danger to yourself or someone else, or 2) when/if I learn of harm or neglect of a disabled person, an elderly person or a child.In addition, 3) a judge or court order may require me to disclose information. This requirement can be appealed. In this case I will disclose as little as possible in order to protect your confidentiality to the best of my ability.
Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your Protected Health Information is stored in locked file cabinets behind locked doors.
Legal Issues and Claims
If you are currently, or have any reasonable expectation of being, involved in any legal or claim related activity of any kind – including but not limited to worker’s compensation, disability, divorce, custody dispute, lawsuit as plaintiff or defendant, DUI or other alcohol or drug related issues – please be aware I will not be able to support your position or advocate for you in this context. Advocating for a client creates a dual relationship (therapist and advocate) which is a violation of my professional ethics. I can serve you only in the capacity of therapist.
I do not participate in legal or claims/benefits related processes. If you would like more information about this, please let me know in person. I will decline (or ignore) requests for involvement in all legal or claims related issues.
In Case of Emergency
If I become aware of an emergency involving your safety, I will contact the people listed on Page 1 of your Client Biography. Do not list anyone as an Emergency Contact whom you do not wish me to contact.
If you are experiencing a psychiatric and/or life-threatening emergency, please follow the following protocol.
Interacting Outside the Office
As your therapist, my most important concern is preserving your safety, security and confidentiality at all times. We will interact within the confines of our scheduled therapy appointments. Should our paths cross outside of these appointments, I will not address you or acknowledge you in public unless you speak to me first.
I am also ethically obligated to decline any social or ceremonial invitations including weddings, funerals and memorial services. Your rights to privacy and confidentiality extend beyond death. These guidelines are strictly for your long-term protection.
I am a Licensed Clinical Social Worker and aspire to offer you the best care I am able that is also in compliance with the ethical standards of the National Association of Social Workers. In addition, as an Advanced Practitioner of EFT Tapping, I also abide by EFT International and the Association of Comprehensive Energy Techniques’ Codes of Ethics. If you have any concerns about the course of our work together, please let me know as soon as possible. My goal is to always make room for your experience and I am very open to having the hard conversations in a very safe way. You may also contact the National Association of Social Workers at https://www.socialworkers.org/ or The Georgia Composite Board of Professional Counselors, Social Workers and Marriage and Family Therapists at https://sos.ga.gov/index.php/licensing/plb/43. In addition, you may contact EFT International at https://eftinternational.org/ about-us/contact-us/ and ACEP at https://www.energypsych.org/.
Due to the nature of psychotherapy, I cannot guarantee specific results. However, my goal is to always provide you the best care and the most relief possible. As we do our work in therapy, the process often becomes difficult before it gets easier. Sticking with the therapy process is the best way to get to the other side and gain relief.
If, at any point, you would like to explore other therapy providers as alternatives, please know that I am supportive and would be happy to assist you with a transition. My only agenda is to help you find what works best for you.
Technology Statement & Telehealth Policies
“Telehealth means the mode of delivering services via technology-assisted media, such as but not limited to telephone, video, internet, smartphone, tablet, laptop, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. Telehealth facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.” (Georgia Code 135-11-.01)
The daily use of the above devices has created the need for high levels of protection of your Protected Health Information. Please read each of the policies below and let me know if you have any questions at all.
About Landline Telephones
• Landline telephones may not be completely secure and confidential.
• There is a possibility that someone could overhear or intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may determine who you have talked to, who initiated that call, and how long the conversation lasted.
• If you have a landline and you provided me with that phone number, I may contact you on this line from my cell phone, typically only regarding setting up an appointment if needed.
• Telephone conversations (other than just setting up appointments) are billed at my hourly rate.
• If this is not an acceptable way to contact you, do not share your landline phone number with me or contact me from your landline phone. By contacting me from your landline phone you are expressly giving me permission to contact you this way.
• Cell phones may not be completely secure or confidential. Someone could overhear or intercept your conversations. Individuals with access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call took place.
• I will use a cell phone to contact you.
• Telephone conversations (other than setting up appointments) are billed at my hourly rate.
• I store your phone number in my cell phone, which is locked at all times.
• If any of this is a problem, please contact me only via HIPAA compliant email at firstname.lastname@example.org and do not provide me your cell phone number or contact me from your cellphone. By contacting me from your cellphone you are expressly giving me permission to contact you this way.
• Text messaging is not a secure or reliable means of communication and may compromise your confidentiality. Use texting to communicate with me infrequently and only to schedule or cancel appointments.
• Appointment cancellations must be made via email at email@example.com.
• If/when you text me, you are waiving your expectations of privacy and confidentiality on this platform and are expressly giving me permission to contact you this way.
• I utilize a HIPAA compliant email platform called HushMail. HushMail has provided me with a Business Associate Agreement which means that the company is also bound by HIPAA compliance rules.
• To email me, I encourage you to open a free HIPAA compliant email account, otherwise your emails to me and the content of my emails will not be secure.
• You should communicate only through a device that you know is safe and technologically secure (has a firewall, anti-virus software, password protected, not using a public wireless network, etc.).
• If you are in a crisis, please do not communicate this to me via voice mail or email because I may not receive it
• in a timely matter. Instead, please see above In Case of Emergency.
Social Media & Identity Theft
• I do not accept “friend” or “connection” requests from any current or former client on my personal or professional social networking sites such as Facebook, LinkedIn, Instagram, etc. because it may compromise your confidentiality and blur the boundaries of our relationship.
• I do not now, nor have I ever, participated in any synchronous interactions on social media of any kind including Facebook Live, You Tube Live, chat rooms, bulletin boards, etc. If you believe you have seen my photo/likeness and/or read/‘heard’ me participate, this was the direct result of identity theft.
• I may post therapeutic and/or educational content on one or more of my professional blogs.
• If you have an interest in following my blog, please feel free to do so.
• However, please be mindful that the general public may see that you are following me.
• Once again, maintaining your confidentiality is my priority.
Electronic Transfer of PHI for Certain Credit Card Transactions
2023 – I use Stripe to process your card payments. This company may send the card holder a text or an email receipt indicating that you used that card for my services, the date you used it, and the amount that was charged. This notification is usually set up two different ways – either upon your request at the time the card is run or automatically. It is your responsibility to know if you or the card holder has the automatic receipt notification set up in order to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally,
please be aware that the transaction will appear on your card statement under the name “ML.LCSW”
Communication Response Time
• I am physically located in the Southeastern United States in Georgia and I abide by Eastern Standard Time.
• My practice is set up to accommodate individuals who are reasonably safe and resourceful. I am not available at all times.
• If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources, including the option to help you transition to a higher level of care or to a therapist of your choosing who can provide greater access.
• For fastest response, please email me at firstname.lastname@example.org. If you do not hear from me promptly, please re-send your email and/or advise me of your email via text.
INFORMATION, AUTHORIZATION & CONSENT TO TREAT USING EFT TAPPING
About EFT Tapping or Emotional Freedom Techniques
We have the option to incorporate EFT Tapping into our work together, along with other modalities. EFT Tapping has a wide range of applications and frequently offers significant relief both in the short-term and the long-term.
DISCLAIMER – Emotional Freedom Techniques, EFT, Tapping & Energy Work
EFT is a treatment method believed to be based on the following well understood mechanisms in the fields of psychology, mental health, and trauma resolution:
• Imaginal Exposure
• Acupressure / Meridian Activation
• Somatic, Emotional and Psychological Processing
• Nervous System Downward Regulation
• Information Processing & Reprocessing
• Cognitive Restructuring
• Memory Reconsolidation and
• Eye Movement & Reprocessing
I am both an EFT Advanced Practitioner and EFT Master Trainer, certified by EFT International (formerly AAMET International). I offer EFT alone as a treatment option and/or as an adjunct to our psychotherapy work together.
EFT Tapping has been used worldwide for 30 years. It uses a gentle tapping procedure to stimulate designated points on the face and body. Research has validated the existence of “meridians” or energy channels in the human body as well as the effectiveness of EFT on relieving and/or eliminating a large number of emotional, psychological and physical symptoms, including those caused by trauma.
Please refer to EFT International’s Research page https://eftinternational.org/discover-eft-tapping/eft-science-research/ to review the large body of research evidence available. I encourage you to get all your questions answered. I am always available to discuss questions or concerns you have regarding EFT in general and/or in your individual situation.
I am required by my profession’s ethical standards to advise you that EFT Tapping is still considered experimental in the United States. EFT is, as of this writing, considered an integrative, complimentary and/or alternative therapy method and its effectiveness, risks, and benefits may not be fully known.
As with all therapy modalities, I cannot guarantee that EFT will cure, heal or completely resolve your distress. As always, I will make every effort to provide you as much relief as possible, as quickly as possible, and with as little distress as possible.
If you would like to incorporate EFT into your therapy with me, or use it outside of sessions, you agree to assume and accept full responsibility for any and all risks associated with this practice.
In using EFT, as in all therapy, it is possible that emotional or physical sensations or unresolved memories may surface, which could be perceived as negative side effects. It is also true that you may achieve significant relief of your symptoms as a result of this practice more quickly than expected.
While I always use EFT in my practice in good faith and with good intentions, there may be times when EFT presents us with challenging, unforeseen situations, or when EFT does not result in the desired positive outcome.
EFT is not a substitute for medical or mental health treatment. You agree to consult with your medical and/or mental health providers for medical, psychiatric or physical problems, symptoms or concerns.
INFORMATION, AUTHORIZATION & CONSENT TO TREAT VIA TELEHEALTH
Video Conferencing and Telehealth
• We may conduct remote sessions over the internet where we can see and speak to one another.
• I use a HIPAA compliant platform for all video sessions.
• This means the platform has provided me with a Business Associate Agreement (BAA) which means the company assumes responsibility for keeping the platform secure and confidential.
• If we choose to utilize this technology, I will send you a link to our session.
• I ask that you be prepared to connect via the link (no downloading required), have checked your microphone and your camera, and if possible, use a headset or earplugs.
• I strongly suggest that you only communicate through a computer or device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).
• Additionally, you agree not to record any Telehealth sessions.
• There are special safety procedures that I follow during Telehealth sessions.
Emergency Procedures Specific to Telehealth Services
There are additional procedures that we need to have in place specific to Telehealth services.These are for your safety in case of an emergency and are as follows:
• If you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or are in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telehealth services are not appropriate.
• I require two local Emergency Contacts who I may contact on your behalf in a psychiatric emergency only, which you have provided on Page 1 of your Client Biography. You or I will verify that your Emergency Contacts are willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECs, or I determine necessary, the EC agrees to take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact these individuals in the extreme circumstances stated above. Please list your ECs here:
In Case of Technology Failure
During a Telehealth session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a charged phone with you, and I have that phone number.
If we get disconnected from a video conferencing or chat session, end and restart the session. If we are unable to reconnect within ten minutes, please call me.
If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session. If the issue is due to my phone service, and we are not able to reconnect, I will not charge you for that session.
Structure and Cost of Sessions
I offer primarily Telehealth services. When I return to offering in-person sessions again, this new location will always be posted clearly on my website.
The structure and cost of Telehealth sessions arethe sam e as face-to-face sessions described in my general “Information, Authorization, and Consent to Treat” form. At the end of our Telehealth Session you will provide payment via card information, and this will be processed using Stripe, usually within the week. Your payments for therapy will be listed as “ML.LCSW” on your statement for your privacy and confidentiality.
Insurance companies have many rules and requirements specific to certain benefit plans. At the present time, many do not cover Telehealth services. (Note: If they cover it, it’s generally for video conferencing only). It is your responsibility to find out your insurance company’s policies and to file for insurance reimbursement for Telehealth services. As stated above, I will be glad to provide you with a Superbill (Statement) for your insurance company and to assist you with any questions you may have in this area.
The CPT Code for a 55 Minute Telehealth Session is 90837-95/GT, with Location code 02.
You are, of course, responsible for the cost of any technology you may use at your own location. This includes your computer, cell phone, tablet, internet or phone charges, software, headset, etc.
If you are unable to keep a scheduled appointment, you must notify me at least 48 hours in advance or you will be financially responsible for the session you missed.
Limitations of Telehealth Therapy Services
Telehealth is an alternative form of therapy or adjunct therapy, and it has limitations. Primarily, there is a risk of misunderstanding one another when communication lacks sufficient visual, auditory or energetic cues. My ability to discern various aspects of your experience may be diminished when we are not in the same room together.
There may also be a disruption to the service (phone gets cut off or video drops) which may interrupt the normal flow of personal interaction.
Please know that I have the utmost respect and positive regard for you and your wellbeing. I would never do or say anything intentionally to hurt you in any way, and I strongly encourage you to let me know if something I’ve done or said has upset you. I invite you to keep our communication open at all times to reduce any possible harm and I will do my very best to cultivate an atmosphere of safety and security.I agree to provide psychotherapy to you for our agreed upon fee. The fee for each session is due at the conclusion of the session. You may pay using Credit Card, Debit Card, Flexible Spending Account Card, or Health Savings Account Card. For accounting reasons, I do not accept cash or checks.
I recognize that all cancellation reasons are valid. If you are unable to keep an appointment, you must notify me at least 48 hours in advance or you will be financially responsible for the session you are unable to attend.
Because texting is unreliable, cancellations are accepted via email only at email@example.com.
Our Agreement to Enter into a Therapeutic Relationship
If you have any questions about any part of this document, please ask me. This is a legal document. However, I am open to any questions you may have about any of it.
Please print, date, and sign your name below indicating that you have read, understand and agree to all of the contents of this “Information, Authorization and Consent to Treat” form in its entirety.
Your signature indicates that you agree to the policies of your relationship with me, and that you are authorizing me to begin treatment with you. I am very pleased to have the opportunity to work with you.
© melissalesterlcsw.com 2023