Informed Consent

At Poppy’s Therapeutic Corner, LLC, it is your therapist job to assist you in experiencing relief and new growth after the droughts of life. Your therapist is excited and grateful to work with you, and looks forward to sharing in your transformations as we go forward.

This document contains information regarding both our business policies and our professional services. It will inform you about the Health Insurance Portability and Accountability Act (HIPAA), which is a federal law that provides you with protection and rights regarding the disclosure and use of your protected health information (PHI) for the purposes of payment, treatment, and health care operations.

Documents like this one are often long and complex. However, it is important to read it thoroughly. We will go over its contents with you as well and answer any questions you may have during your first session. Your signature on this document, as well as ours, represents an agreement between us. So it is imperative that we are clear about that to which we are agreeing. Thank you for being patient and reading it carefully.

The relationship that you and your therapist will establish is part of what makes therapy and/or the evaluation successful. Trust is an essential part of that relationship. In order for you to be able to trust us, it is necessary that you are aware of both your rights and responsibilities, and of the legal limitations to those rights. We also have responsibilities to you as your therapist, which you should be aware of. These are all described in the following sections of this document.

In our professional work, we are firm and enthusiastic believers in professional organizations and codes of ethics as methods by which we hold ourselves accountable and by which you, as our client, can hold us accountable. They offer guidance in difficult situations. It is important for you to know our credentials, so that you know what standard of care we should be providing you, as well as who to contact should you feel your therapist or case manager is doing something unethical. We are licensed by the state of Ohio as a Licensed Professional Counselor and/or Licensed Professional Social Worker.

As all professional counselors and social workers in Ohio do, we work under supervision and direction. This ensures that providing you with the highest quality of care possible, and provides you with a person to contact, should you ever need to, regarding the care we have provided. Our clinical supervisor is. Ms. Jennifer M. Sheard, LPCC-S. They can be reached by calling 513.570.4068 or emailing; info@poppystherapeuticcorner.com.

Throughout the course of our time together, we will set many goals for the outcome of counseling. Some will be short term (such as what you would like to discuss in a given session). Some will be long term (like lessening feelings of discomfort and improving the overall quality of your life). These goals will be set by you according to what you want to accomplish. I will work with you in establishing these goals and of course work with you toward achieving them. But you will have the control and will ultimately determine which direction our work together will take.

Counseling can be a difficult and intense process at times. We will discuss topics which may initially cause you discomfort, such as unpleasant experiences or emotions. There are also no guarantees that it will be successful for you. Sometimes clients make progress only to regress after a time. It will challenge your ways of thinking, your previously held beliefs, and will identify areas for change.

Most important to know is that the counseling process takes time and commitment. It requires patience from both of us. Some clients will experience some relief after one or two sessions, and will then cease counseling, feeling that they are better. Your therapist or school psychologist does NOT recommend this, as it can be far more detrimental over the long term. Lasting change is best accomplished by engaging the full process from initial consultation through goal setting and feedback, through treatment planning, through implementation, all the way to termination. Each step is carefully planned and engaged by both yourself and by your therapist or school psychologist. Throughout the process, as well, you will have to work on things that we discuss outside of our session time. You may have new behaviors to try, things to read, or a journal to write. These “homework assignments” are completely voluntary. Your therapist or school psychologist will never ask you to undertake anything that you are not willing or able to do.

Your provider will do whatever is legally and ethically appropriate and allowable, to the best of his/her skills and abilities, to keep your personal information private. What you say in therapy and/or case management session is covered by legal confidentiality, so long as it falls within the legal limitations. Those limitations are as follows: 

● If your provider has a concern that you are in any way in danger of hurting yourself or others, we are required by law to contact the appropriate authorities. 

● If your provider has a concern that a child or an elder is being abused by anyone (not necessarily yourself) as a result of our conversations in session, we are required to report it to the appropriate authorities. 

● If we are subpoenaed by a court of law to present information regarding your care, or to testify regarding your care, we may be required to do so depending on the situation. In all situations where confidentiality must be broken, your therapist is committed to informing you as much as is ethically required and appropriate. Your provider, in any of these situations will consult with his/her supervisor, his/her director, and other professionals prior to taking any action. And your provider will limit any such release to only what is required by law and code of ethics. 

In all other circumstances, such as coordinating care with another care provider, your provider requires that you sign a release of information authorization in order to discuss your treatment. 

Your provider will be keeping records of your sessions, such as names of people that you mention, details of experiences which we think are therapeutically important, goals we discuss, or impressions that we have. These notes are kept so that we do not forget important details, so that we can ensure a direction with your care, and to ensure continuity of care should anything happen to your provider. These records will not be shared with anyone except with respect to the limits of confidentiality detailed above. Should you wish to have copies of your records or have them released, we will require a signed release, and will release whatever is ethically appropriate and maintain your privacy to the best of our ability. Our records at Poppy's Therapeutic Corner, LLC are kept both electronically and manually (on paper). Our online system is HIPAA compliant, secure, and paper files are kept in a locked filing cabinet. Records are kept for an indefinite amount of time. 

 

Should anything happen to your provider, such that we are no longer able to provide you care (such as accident or death), you will be contacted by one of our partners here at Poppy’s Therapeutic Corner who will ensure the continuity of your care. He or she will access your records only as is necessary to provide continuity of care. In addition, should you wish to be provided with a contact during times when your provider is on vacation, we are happy to connect you with our partners so that they can provide care for you while your provider is gone at your request.

Provider appointments last for fifty minutes and are typically once per week in frequency at a regular time. Evaluation appointments last anywhere from one to two hours and are typically once per week in frequency at an agreed upon time However, if you would prefer that they be more or less frequent, we can schedule them as needed. If you need to cancel or reschedule a session, notice must be provided at least 24 hours in advance in order to avoid a cancellation fee equal to your session fee (unless we both agree that you were unable to come due to circumstances beyond your control).

Therapist professional fees are $85 per hour for individuals, $100 for couples and family counseling. It is due at the beginning of each session. 

You may pay by cash, credit, or debit card. I reserve the right to involve an attorney or collection agency to collect fees that are owed if necessary.

Professional fees are subject to change due to continuing education, licensure, and specialization. If our fees increase, you will be notified no less than four sessions in advance, so that we can discuss any concerns that you have prior to the increase.

If at any point during our time together you anticipate being involved in a court case which will require my involvement, we will need to discuss this in advance, as payment is required for the professional time that your therapist or school psychologist will spend on your case.

We accept the following insurances:

• Caresource
• Anthem Medicaid
• Molina
• Optum
• Aetna OhioRise
• Buckeye
• Humana Horizon
• Ambetter
• United Healthcare
• Humana
• Aetna (Commerical)
• Anthem BCBS
• Ameri Health
• Medicare Part B

Depending on your current health insurance provider or employee benefit plan, it is possible for services to be covered in full or in part. Please contact your provider to verify how your plan compensates you for psychotherapy services.

 We’d recommend asking these questions to your insurance provider to help determine your benefits:

Does my health insurance plan include mental health benefits?
Do I have a deductible? If so, what is it and have I met it yet?
Does my plan limit how many sessions per calendar year I can have? If so, what is the limit?
Do I need written approval from my primary care physician in order for services to be covered?

For evaluations, if you need a DSM V diagnosis for a learning disability due to needing accommodations on your job, etc. This can be arranged.

Each therapist will provide their work cell number to you at the end of your first session. Please contact your therapist to reschedule or cancel an upcoming session.

If it is an emergency, please call the Ohio Crisis and Access line at 1.800.273.8225, go to your local hospital emergency room, or call 911 for help.

We will provide you with our work email addresses. We do utilize the tool of email as long as you are comfortable with it for the purpose of rescheduling or canceling an upcoming session. If you prefer not to receive emails, please let us know by indicating in the space below.

 

Telehealth Consent:

Poppy’s Therapeutic Corner offers telehealth services as an option for therapy sessions. Telehealth involves the use of electronic communications to provide clinical services remotely. This may include video conferencing, audio communication, and other forms of digital interaction.

By signing this consent form, you acknowledge and agree to the following:

Technology Use: Sessions will be conducted using HIPAA-compliant, secure, and encrypted platforms such as Zoom, Doxy.me, or Google Meet (paid versions). These platforms are selected to protect your privacy and confidentiality.

Privacy & Confidentiality: Every effort will be made to ensure confidentiality, just as in in-person sessions. However, there are potential risks, including technical issues, interruptions, or unauthorized access. You are responsible for ensuring privacy on your end (e.g., using a private space for sessions).

Emergency Situations: Telehealth is not appropriate for crisis situations. If you are in immediate distress or experiencing an emergency, please call 911 or go to the nearest emergency room.

Technology Limitations: Telehealth services rely on internet connectivity and device functionality. In the event of technical difficulties, an alternative communication method (such as a phone call) may be used to complete the session.

Consent to Participate: You understand that telehealth is a voluntary service and can be discontinued at any time by you or your provider if deemed clinically necessary.

By signing below, you consent to participate in telehealth services with Poppy’s Therapeutic Corner and acknowledge that you have read and understand the above information.

It is our policy not to connect with clients on social media outlets such as Facebook or Instagram. We maintain a Facebook page (Poppy’s Therapeutic Corner) to which you are welcome to subscribe. However, it is highly important to maintain professional and ethical boundaries within our therapeutic relationship. For that reason, please do not be offended if we do not accept friend requests.

It is our policy that when attending sessions to please be prompt and on time. There will be a 15 minute courtesy for those individuals who have notified the therapist of his/her tardiness. In addition, for family and couples sessions, the expectations is that all parties involved are respectful to one another and participate throughout the entire session.

The termination process of counseling can be difficult. We will move toward termination at whatever pace is comfortable and therapeutically beneficial for you. We will discuss the termination process beginning no less than four sessions prior to its occurrence, and your provider will do his/her best to help ensure that the transition is smooth and successful for you. Please know that after we have terminated our regular sessions, your therapist/school psychologist will remain available for “check-ins” by phone and email, as well as occasional “well visits.”

If you so choose, you are within your rights to terminate your care at any time. All records of your care will be kept confidential (within the limitations detailed above) even after your care has been terminated. Please know that your provider will do his/her due diligence in assuring your well-being if you have ended counseling suddenly. Your provider will do this by calling, emailing, and sending a follow up letter to formally terminate care if that is your desire.

In all cases of termination, please expect an email and/or letter from your provider terminating care and requesting your feedback by various methods (such as an online survey). He/she will also conduct occasional follow up calls to see how you are doing.

Your signature below indicates that you have read this document and agree to its terms.