Consent for Therapy and Other Participation Terms
This document contains important information about the professional services and business policies of both your Lyra Clinical Associates (“LCA”) therapist, and Lyra Clinical Associates P.C. Please read it carefully and discuss any questions you have with your therapist. By signing this form, you are representing that you have read this document, understand the information found in it, and you agree to comply with it, as applicable.
DO NOT USE OUR SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL OR MENTAL HEALTH EMERGENCY. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (988) or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).
Confidentiality: Your therapist and LCA take your privacy and confidentiality very seriously. LCA complies with Federal and California laws regarding confidentiality of client information. LCA’s Notice of Privacy Practices details how we use any information we collect, including for treatment, coordination of care, payment and other business operations. We will minimize the amount of information we share without your express consent, however we want to bring your attention to certain circumstances in which we may disclose details of your care:
- Your therapist may share information about your assessment and treatment with the clinical team at LCA in a way that minimizes the sharing of your personal information to only that necessary to ensure that we are providing you with the most effective care possible and/or to improve your experience with our services.
- In certain circumstances, your therapist is required by law to inform legal authorities, or potentially impacted individuals, regarding the following possibilities:
- If there is suspected abuse or neglect of an elder, incapacitated or dependent adult, or child.
- If, in your therapist’s judgment, you are in danger of harming yourself or another person, or are unable to care for yourself.
- If you communicate to your therapist a serious threat of physical violence against another person.
- If your therapist is ordered by a court to release information as part of a legal proceeding, your therapist may be required to share details of your care.
- As otherwise required by law and/or detailed in our Notice of Privacy Practices.
The Process of Psychotherapy: The process and outcome of psychotherapy may vary depending on the particular problems addressed, the personalities of the therapist and client, and various other factors. While we cannot predict exactly what your experience will be like, we are committed to providing you with the most professional and ethical treatment possible.
Participation in therapy can result in a number of benefits to you, including improved interpersonal relationships, resolution of specific problems, and positive personal change. In order for therapy to be successful, you will need to make an active effort both during and outside of your sessions. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable and intense feelings like sadness, guilt, anxiety, frustration and anger. In addition, it may result in changes that were not originally intended (such as divorce or remaining in a relationship you believed you would leave). Change can often happen quickly, but may also occur more slowly. There are no guarantees about what you will experience. Your therapist’s role is to help guide you through the therapy process by offering emotional support, actively listening to your concerns, asking relevant questions, providing treatment plans and recommendations, and monitoring your treatment progress.
During your first session, you will discuss with your LCA therapist the reasons you are seeking therapy, goals you would like to achieve, and any background information related to your presenting concerns. In subsequent sessions, you and your therapist will work collaboratively towards achieving your goals of therapy. Subsequent sessions may focus on understanding thought patterns, feelings, and behaviors that are relevant to presenting concerns and work towards more effective ways of coping.
Throughout therapy, you will work with your therapist to tailor treatment to meet your goals and assess whether your goals are being met. If at any point you are unhappy about the progress, process, or outcome of the treatment, please discuss this with your therapist. There are many different methods your therapist may use to address the concerns that bring you to therapy. Your therapist strives for genuineness and a nonjudgmental stance in all of his/her patient relationships. However, if at any time you feel that you are not connecting or that he/she has misunderstood you in an important way, you should discuss them in session with your therapist. In addition, the Lyra Care Navigator Team is always available to work with you, and may also reach out to you to discuss your overall satisfaction with the therapy.
Your Therapist’s Credentials. Your therapist’s credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your therapist. For those states that require it, you can find an explanation of the levels of regulation applicable to mental health clinicians under the STATE REGULATIONS section of this document. Please let your therapist know if you will be traveling to another state or if you move to another state. In some cases, therapists are not able to provide services to you while you are located in another state, even temporarily.
Billing and Payments: The fees for your sessions may be partially or fully paid for by your, or your eligible sponsor’s, employer or Health Plan, with or without any cost share to you, as long as you are an eligible employee in good standing with the company, and as long as further sessions are considered clinically appropriate. If you are participating in self-pay care, you are fully responsible for all session costs and any other fees. Lyra’s services are not covered by Medicare. If you have insurance coverage through Medicare, you are financially responsible for any costs that are not covered by your employer or another Health Plan in which you are enrolled. Please note that certain professional services outside of the presenting problems may be outside the services paid for by your employer or Health Plan and may incur additional fees. Any additional fees will be discussed and agreed upon when they are requested. Fees for services may be subject to change in the future and may also change if you move to another state. If you have questions about the full cost of a session prior to any health plan cost coverage, you may contact the Lyra Care Navigator Team at [email protected]
The Lyra Website: As part of therapy you will use the Lyra Website. You will need to access the Lyra Website to participate in the video sessions, submit assessments and practices in between sessions, as well as to connect with your therapist via secure messaging.
Your therapist will orient you to using the Lyra Website for the above purposes during your first therapy session. If you decide to have your sessions with your therapist by phone (without using the video option in the Lyra Website), your therapist will call you at the number you provided at registration. You will still need to use the Lyra Website to complete assessments and submit records of therapy practices.
Therapy Assessments: Before your first session, your therapist will ask you to answer a set of questions that will help them get to know you and better tailor treatment to respond to your situation. Throughout therapy, your therapist will also assign other assessments to be completed before your sessions to inform treatment.
Therapeutic Focus: LCA therapists may decline to make recommendations, write letters of recommendation or complete application forms related to medical leave, medical disability, fitness to work, child custody, or emotional support animals if they believe it is outside the scope of their competency or licensure, or otherwise not clinically appropriate.
Video Therapy: Please note that:
- As part of this program you may engage in telehealth sessions with your LCA therapist.
- All telehealth sessions are held by video using the Lyra Website.
- Your therapist will initiate the video session with you at the scheduled time using the Lyra Website.
- The video conferencing technology will not be the same as an in-person session with a therapist due to the fact that you will not be in the same room as your therapist.
- In order to have the best results for your video session, you should be in a quiet place with limited interruptions when you start the session.
- There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties that are beyond the control of LCA. You agree to hold LCA harmless for delays in evaluation or for information lost due to such technical difficulties or failures.
- Generally speaking, telehealth offers benefits such as improved access to care by enabling patients to remain in their local site (e.g., home or work) while their clinician consults at distant/other sites, efficient mental health evaluation and management, and the expertise of specialists that patients otherwise might not have. There are potential risks associated with telehealth, which include, but may not be limited to: the therapist may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with you; delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; security protocols could fail, causing a breach of privacy of personal medical information; lack of access to complete medical records, which could result in judgment errors in rare cases; and, it may become clear that telehealth is not an appropriate treatment format given your presenting symptoms or level of functioning, resulting in a recommendation that you obtain additional in-person care.
- Your Lyra therapist or yourself can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
- Your LCA therapist will inform you and obtain your consent if another person is present during the consultation, for any reason. For example, persons may be present during the consultation other than the LCA therapist in order to operate the telehealth technologies. You will be informed of their presence in the consultation and will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
- There are alternatives to a telehealth session available, including the option of finding an LCA therapist to see in-person.
- You can direct questions about your telehealth sessions at any time to your LCA therapist or Lyra Care Navigator Team member.
- This consent will last for the duration of the relationship with your LCA therapist, and it covers all telehealth sessions you may have.
- You can withdraw your consent for telehealth sessions in the course of your care at any time for any reason or no reason, without affecting your right to future care or treatment, and Lyra will work with you to find a suitable alternative.
- The same confidentiality protections, limits to confidentiality, and rules around your records apply to a telehealth session as they would to an in-person session.
- Your LCA therapist may decide to terminate telehealth services, if they deem it inappropriate for you to continue therapy through video sessions. Your LCA therapist will work with other team members to identify another LCA therapist for in-person care.
- You understand that while you may expect anticipated benefits from the use of telehealth in your care, no results can be guaranteed or assured.
- By signing this consent form you agree to work with your LCA therapist to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during your sessions.
Video Recording: Your therapist will ask you at the start of each session if you consent to the session being recorded. If you consent, your therapist will record the session to enable preparation of a draft summary note of the session, using our artificial intelligence tools, and for the purposes of quality assurance, training, and the development and improvement of our services and artificial intelligence tools. The draft note will be reviewed by your therapist prior to inclusion in the clinical record.
Video recordings are kept securely for 2 weeks and then deleted. No one other than the therapist (including you) has permission to record sessions.
Content of the session may be retained indefinitely in a de-identified and/or aggregated format, and used for quality assurance, training, and the development and improvement of our services and artificial intelligence tools.
Your participation in video recording is voluntary. You have the right to refuse to be recorded and to withdraw your consent at any time. Choosing not to be recorded will not affect the availability or quality of the care you receive.
Your Location During Video Sessions: Like all health care providers, LCA’s therapists are licensed to offer services on a state by state basis. In order to ensure your LCA therapist is appropriately licensed, we ask that you please search for a provider based upon your planned location at the time your session takes place. If your location changes at any point from one state to another, please let your LCA therapist know as soon as possible. Please be aware that your LCA therapist may not be able to provide services when you travel to a different state and is not able to provide services when you travel outside of the U.S.
Missed Appointments and Cancellations: Your therapist requires at least 24 hours advance notice for cancellation of an appointment. If you are unable to attend your scheduled appointment due to circumstances beyond your control, please message your therapist in the Lyra Website as soon as possible so we can reschedule your appointment to a more suitable time. Once an appointment is scheduled, you will be expected to attend unless you contact your therapist to reschedule. You can also use email to reschedule; however, please note that receiving emails in your personal account may be unsecure. Failure to provide sufficient notice for cancellations and/or repeated no-shows for your appointment may impact your ability to schedule additional appointments with your therapist. If you cancel or reschedule within 24 hours of a scheduled session, or you do not attend a scheduled session you may be charged a $105.00 Late Cancellation Payment.
In-Between Session Communication: If you need to contact your LCA therapist between sessions, for non-urgent issues, please message them within the Lyra Website. Your therapist checks his/her messages in the Lyra Website regularly during business hours and will make every effort to return your message within 2 business days. These messages will remain available for thirteen (13) months and then will be deleted.
Emergency Procedures: In a crisis, please call 911 or go to the local emergency room. Please do not use the Lyra Care messaging or email if you are experiencing an emergency. If you would like to speak to someone for support prior to your therapy appointment, or if you experience distress prior to your appointment, please use the Lyra Care Navigator Team number (877-505-7147) for non-emergency situations. Your Lyra therapist may not be available to respond to you immediately due to variations in working hours. Your Lyra therapist will respond to messages within 48 business hours of receipt.
If you experience an emergency during your sessions with your LCA therapist, or if your LCA therapist becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, your LCA therapist and LCA will do whatever possible within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, LCA or your LCA therapist may contact the person whose name you have provided on the biographical sheet as your emergency contact.
Social Media Policy: LCA and our therapists believe that adding clients as friends or contacts on social media sites (e.g., Facebook, LinkedIn, etc.) can compromise clients’ confidentiality and privacy. Consequently, given the importance of client confidentiality, your LCA therapist will not accept friend or contact requests from current or former clients on any social networking site. If you have questions about this, please bring them up during your session.
Research, Writing, Teaching: Your therapist and others at LCA conduct internal research to improve our services, training, and supervision, or publish information for professional and/or lay audiences. De-identified information about you and your treatment may be used to support these initiatives. Any use of information about your treatment would be only in an anonymized and/or de-identified way for these publications.
Length of Therapy: Evidence-based treatments, or treatments that have been rigorously tested and proven to be helpful, typically are shorter-term treatments than general counseling or the general provision of support. Most clients notice some initial changes or relief within the first few sessions of treatment. Your course of treatment will be individualized depending on the intensity and duration of your presenting concerns, your level of engagement and active participation in the treatment plan, and the specific nature of your concerns.
Ending Treatment: You may withdraw from treatment at any time. Your therapist recommends that you discuss your plan to end treatment with them before taking action, so that they have an opportunity to offer further recommendations or referral options.
If at any point during psychotherapy your therapist assesses that the sessions are not effective in helping you reach the therapeutic goals, he/she will discuss this with you and, if appropriate, end treatment. In such a case, they will work with you and the Lyra Care Navigator Team to identify alternative options.
If you do not keep your scheduled appointments and do not respond to communications from your therapist, we will assume you have elected to end your treatment and we will close your case. If this occurs, and you wish to resume your treatment, please contact the Lyra Care Navigator Team to reinitiate therapy.
State Regulations: Please read the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below.
| State | What You Should Know | Relevant Board Contact Information |
|---|---|---|
| Alaska | You understand that your primary care provider may obtain a copy of your records of your telehealth encounter.
This document is intended to provide you with all of the information is required by the Board of Professional Counselors which regulates all licensed professional counselors. You may contact the Board with any questions or concerns. Alaska Stat. § 08.63.210(c)(2). |
Board of Professional Counselors, Marital and Family Therapy and Social Workers
Division of Corporations, Business & Professional Licensing P.O. Box 110806 Juneau, AK 99811-0806 Phone: (907) 465-2551 (for Social Work); (907) 465-2550 (for Professional Counselors and Marriage and Family Therapists) Email: [email protected] ; [email protected] ; and [email protected] |
| Arizona | You are entitled to all existing confidentiality protections, including where a provider may only disclose all or part of your medical record and payment record as authorized by state or federal law or written authorization signed by you or your health care decision maker, pursuant to A.R.S. § 12-2292. You also understand all medical reports resulting from the telemedicine consultation are part of your medical record as defined in A.R.S. § 12-2291. You also understand dissemination of any images or information identifiable to you for research or educational purposes shall not occur without your consent, unless authorized by state or federal law. Ariz. Rev. Stat. Ann. § 36-3602(D). See also Ariz. Admin. Code § 4-6-1101
Pursuant to Ariz. Admin. Code § 4-6-1102 your provider will:
|
Board of Behavioral Health Examiners
1740 West Adams Street, #3600 Main Number: 602-542-1882 Fax Number: 602-364-0890 |
| California | The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
You understand that you have the right to refuse care from a trainee without penalty. Cal. Code Regs. Tit. 22, §92309. |
Board of Behavioral Sciences
1625 North Market Phone: (916) 574-7830 |
| Colorado | You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4. The confidentiality of your individual records, including all medical, mental health, substance use, psychological, and demographic information shall be protected with the applicable state and federal laws and regulations, as provided under 2 CO ADC 502-1:21.170.2. 2 CO ADC 502-1:21.170.2.
You understand that your mental health records may not be maintained after the seven-year period for filing a complaint pursuant to Colorado Rev. Stat. 12-245-226 (1)(a)(II)(A). You further understand, in accordance with Colorado Rev. Stat. 12-245-216:
If an unlicensed psychotherapist is involved in your care, your understand that such provider is a psychotherapist listed in the state’s database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. You have been provided in writing the following information regarding your provider: The name, business address, and business phone number of the licensee, registrant, or certificate holder. |
State Board of Licensed Professional Counselor Examiners, State Board of Social Work Examiners, State Board of Marriage and Family Therapist Examiners, State Board of Addiction Counselor Examiners, and State Board of Psychologist Examiners
1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800 Email: [email protected] |
| Connecticut | You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask you whether you consent to that provider’s disclosure of records concerning the telehealth interaction to your primary care provider. You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent. Conn. Gen. Stat. Ann. § 19a-906(d). | Connecticut Department of Public Health, Practitioner Licensing and Investigations Section
Professional Counselor Licensure 410 Capitol Ave., MS #12 APP Phone: (860) 509-7603 Fax: (860) 707-1980 Email: [email protected] |
| District of Columbia | You have been informed of alternate forms of communication between you and a physician for urgent matters. D.C. Mun. Regs. tit. 17, § 4618.10. Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. D.C. Mun. Regs. tit. 17, § 4618.9. | DC Health
2201 Shannon Place SE, Phone: (877) 672-2174 Fax: (202) 727-8471 Department of Health Board of Medicine 899 North Capitol Street, NE Email: [email protected] |
| Georgia | You have been informed that you may be treated by a therapist that is in training and is being supervised and have been given the name of the supervisor.GAC 510-4-.02.10. | Georgia Board of Professional Counselors, Social Workers and Marriage and Family Therapists
237 Coliseum Drive Phone: (404) 424-9966 |
| Idaho | You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708. | Division of Professional Licenses: 11351 W. Chinden Blvd., Bldg. #6 Boise, ID 83714 |
| Kansas | You understand that if you have a primary care or other behavioral health treating provider and if you consent to us sharing your information with such provider, then we are obligated to send within three business days a report to such primary care or other treating physician of the treatment and services rendered by [PC] during the telemedicine encounter. Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A).
The process for filing a complaint may be found here: http://www.ksbha.org/complaints.shtml You have been informed whether your licensed psychologist has either a master’s degree or a doctoral degree. If your licensed psychologist has a doctoral degree, you have been informed whether or not such doctoral degree is a doctor of medicine degree or some other doctoral degree. If your licensed psychologist does not have a medical degree, you understand they are not authorized to practice medicine nor prescribe drugs. Kan Stat. Ann. § 74-5350. You understand some licensees are not authorized to practice medicine and surgery and are not authorized to prescribe drugs. You have been advised that certain mental disorders can have medical or biological origins, and that you should consult with a physician. Kan. Stat. Ann. §65-5817. |
Kansas Board of the Healing Arts
800 SW Jackson, Lower Level – Suite A, Topeka, KS 66612 (785) 296-7413; Fax (785) 368-7102 |
| Louisiana | You understand the role of other health care providers that may be present during the consultation, other than the LCA provider. 46 La. Admin. Code Pt XLV, § 7511. | Licensed Professional Counselors Board of Examiners
11410 Lake Sherwood Ave 225-295-8444 (phone) |
| Maine | If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. | Complaint Coordinator Office of Licensing and Registration
35 State House Station Augusta, ME 04333 Tel: (207) 624-8660 |
| Maryland | The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. Md. Code Regs. 10.41.06.04.
Information provided in this consent is required by the Board of Professional Counselors and Therapists, which regulates all licensed and certified counselors and therapists. Maryland Health & Occ. Code § 17-507. |
Board of Professional Counselors and Therapists
4201 Patterson Ave., |
| Michigan | If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. Mich. Comp. Law 333.18113. | Professional Licensing, Department of Licensing and Regulatory Affairs
Ottawa Building 611 W. Ottawa P.O. Box 30004 Lansing, MI 48909 Phone: 517-241-0199 Fax: 517-241-9416 Email: [email protected] |
| Nebraska | If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records.
Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05. |
Nebraska DHHS Licensure Unit
Attn: [insert relevant profession] PO Box 94986 Complaints: https://dhhs.ne.gov/Pages/Complaints.aspx |
| New Hampshire | You understand that the provider may forward your medical records to your primary care or treating provider. N.H. Rev. Stat. § 329:1-d. | Office of Professional Licensure & Certification
7 Eagle Square Phone: 603-271-2152 |
| New Jersey | You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. N.J. Rev. Stat. Ann. § 45:1-62. | New Jersey Board of Medical Examiners
(609) 826-7100 Professional Counselors Examiners (973) 504-6582 |
| Ohio | You understand that the provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).
You have been advised of our fees. This information is required by the counselor, social worker, and marriage and family therapist board, which regulates the practices of professional counseling, social work, and marriage and family therapy in this state. Ohio Rev. Code § 4757.13. |
Counselor Social Worker & Marriage and Family Therapist Board
77 S High St 24th Floor, Phone: (614) 466-0912 Email: [email protected] |
| Oregon | If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07.
All providers agree to adhere to the Oregon Licensing Board’s Code of Ethics set forth in OAR Chapter 833, Division 100. See Or. Admin. Rule 833-075-0050. You have the right:
Additional information about this counselor or therapist is available on the Board’s website: www.oregon.gov/oblpct. Or. Admin. Rule 833-075-0050. |
The Board of Licensed Professional Counselors and Therapists
3218 Pringle Rd SE, #120, Telephone: (503) 378-5499 Email: [email protected] Website: www.oregon.gov/OBLPCT |
| Pennsylvania | If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you.
You also understand that you may be asked to confirm your consent to behavioral health or telepsychiatry services. 40 PS §1303.504(b). |
State Board of Social Workers, Marriage and Family Therapists and Professional Counselors
P.O. Box 2649, |
| South Carolina | The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health practitioner is also mandated by standards – through Duties to Warn – to breach confidentiality if: (1) you are threatening self-harm or suicide; (2) you are threatening to harm another or homicide; (3) a child has been or is being abused or neglected; and/or (4) a vulnerable adult has been or is being abused or neglected. S.C. Code 40-75-190.
You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time. |
South Carolina Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists
P.O. Box 11329, Telephone: 803-896-4652 |
| Tennessee | You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a telehealth recipient. TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024).
The information you share in psychotherapy is protected health information and is generally considered confidential by both Tennessee state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health provider may also disclose information without consent: (1) if disclosure is necessary for other duties that the mental health provider is bound by, (2) if it is necessary to assure service or care is the least drastic means, (3) due to a court order, (4) if it is solely information to a residential service recipient, (5) to facilitate continuity of service to another health care provider, (6) if a custodial agent for another state agency that has legal custody of the service cannot perform the agent’s duties, or (7) it is necessary for the preparation of a post-mortem examination. Tenn. Code Ann. §33-3-105. |
Tennessee Department of Health
710 James Robertson Parkway |
| Texas | You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005.
You have been informed of the following notice: NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us. AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us You have been advised of the name, address and telephone number of the Council for the purpose of reporting violations. Tex. Admin. Code Rule § 681.35 |
See column to left.
Texas Behavioral Health Executive Council George H.W. Bush State Main Line: (512) 305-7700 Investigations/Complaints |
| Utah | You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602. | Utah Division of Licensing, Behavioral Health Professions (Bureau 8)
Phone: (801) 530-6628 and (866) 275-3675 Toll-Free in Utah Email: [email protected] |
| Vermont | You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by LCA does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. Vt. Stat. Ann. § 9361.
You have been provided with statutory definitions of unprofessional conduct (26 V.S.A. § 3016 and 3 V.S.A. § 129a). Vt. Admin. Code 20-4-1600: 6.8 [concerning psychologists] and Vt. Admin. Code 04-030-040:7.1 [concerning social workers]. The Board of Allied Mental Health Practitioners oversees all licensed mental health providers. If you either wish to make a consumer inquiry or, or file a complaint with this Board, your inquiry or complaint may be addressed to the Board at the Contact Information provided at the right. Vt. Admin. Code 20-4-1600: 6.8 [concerning psychologists] and Vt. Admin. Code 04-030-040:7.1 [concerning social workers]. Upon the Office of Professional Regulation’s receipt of a complaint, an administrative review determines if the issues raised are covered by the applicable professional conduct statute. If so, a committee is assigned to investigate, collect information, and recommend action or closure to the appropriate governing body. All complaint investigations are confidential. Should the investigation conclude with a decision for disciplinary action against a professional’s license and ability to practice, the name of the license holder will then be made public. |
Consumers who have inquiries or wish to obtain a form to register a complaint regarding a professional counselor may do so by calling the Office of Professional Regulation at (802) 828-1505, or by writing to the Director of the Office, Secretary of State’s Office, 89 Main Street, 3rd Floor, Montpelier, VT 05620-3402. |
| Washington | You understand the purposes of and resources available to you surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your needs. RCW 18.19.060.
The information you share in psychotherapy is protected health information and is generally considered confidential by both Washington state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). RCW 18.19.180. Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Clients have the right to choose counselors who best suit their needs and purposes. A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180. You understand that you are not liable for any fees or charges for services rendered prior to receipt of this consent. Wa. Admin. Code 246-810-031. You have been provided copy with a link to the acts of unprofessional conduct in RCW 18.130.180 and the name, address, and contact telephone number within the department of health for complaints. Wa. Admin. Code 246-810-031. |
Here is the name, address, and contact telephone number within the department of health for complaints.
Washington State Department of Health Health Professions Quality Assurance P.O. Box 47865 Olympia, WA 98504-7865 (360) 236-4700 |
| West Virginia | Any questions, concerns, or complaints relating to the delivery of service by your provider, may be directed to the Board using the Contact Information to the right. This information is required by the Board of Examiners in Counseling which regulates all Licensed Counselors. W. Va. Code R. § 27-1-10 | West Virginia Board of Examiners in Counseling
815 Quarrier Street, Suite 212 West Virginia Board of Social Work 1124 Smith St. Suite B, |
| Wyoming | Wyoming has implemented a privileged communication statute that states that, when involved in legal proceedings (civil, criminal or juvenile) clients retain the right to privacy, unless these specific circumstances exist: (a) abuse or harmful neglect of children, the elderly or disabled or incompetent individuals is known or reasonably suspected; (b) the validity of a will of a former client is contested; (c) information related to counseling is necessary to defend against a malpractice action brought by a client; (d) an immediate threat of physical violence against a readily identifiable victim is disclosed to the counselor; (e) in the context of civil commitment proceedings, where an immediate threat of self-inflicted harm is disclosed to the counselor; (f) the client alleges mental or emotional damages in civil litigation or his/her mental or emotional state becomes an issue in any court proceeding concerning child custody or visitation; (g) patient or client is examined pursuant to a court order; or (h) in the context of investigations and hearings brought by the client and conducted by the board, where violations of this act are at issue. Providers will adhere to the Code of Ethics of the National Association of Social Workers; American Counseling Association; American Association of Marriage and Family Therapy; or National Association of Alcoholism and Drug Abuse Counselors, whichever is applicable for the provider’s profession. | Wyoming Mental Health Profession Licensing Board
2001 Capitol Ave, Room 105 Tel: (307) 777-3628 Fax: (307) 777-3508 |
TREATMENT AGREEMENT
If at any time you have questions about the details above, please ask your therapist or the Lyra Care Navigator Team. By continuing your sessions with your therapist you accept and agree to abide by the contents and terms of this agreement and consent to participate in evaluation and/or treatment.