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Consent for Therapy

This document contains important information about the professional services and business policies of both your child’s Lyra Clinical Associates (LCA) therapist, and Lyra Clinical Associates P.C. related to the Lyra Care program. Please read it carefully and discuss any questions you have with your child’s/the minor’s therapist.

Consent from Parent or Legal Guardian: A parent or legal guardian will be required to consent to treatment provided to your child. If the parents of a child are separated, treatment is provided to the child only with the written consent of both parents unless one parent has a custody order authorizing the parent to make medical decisions for the child. If the parents of the child are divorced, consent for treatment of the child may be given by the parent authorized to make medical decisions for the child. If a court of law has ordered that medical decisions for the child are to be made jointly by the child’s parents, then consent of both parents is required for treatment of the child. If applicable, please provide your child’s therapist with a copy of the most recent custody decree that establishes custody rights of you and the other parent, or otherwise demonstrates that you have the right to authorize treatment for your child.

Confidentiality: Your child’s therapist and LCA take your child’s privacy and confidentiality very seriously. LCA complies with Federal and applicable state laws regarding confidentiality of client information. LCA’s Notice of Privacy Practices explains the 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 or your child’s express consent, however we want to bring your attention to certain circumstances in which we may disclose details of your child’s care:

  • Your child’s therapist may share information about your child’s assessment and treatment with the clinical team at LCA in a way that minimizes the sharing of their personal information to only that necessary to ensure that we are providing your child with the most effective care possible and/or to improve your experience with our services. 
  • In certain circumstances, your child’s therapist may be required by law to inform you, legal authorities, or potentially impacted individuals, regarding the following possibilities:
    • If there is suspected elder, dependent adult, child abuse or neglect.
    • If, in the therapist’s judgment, your child is in danger of harming themself or another person.
    • If your child communicates to your therapist a serious threat of physical violence against another person.
  • If your child’s therapist is ordered by a court to release information as part of a legal proceeding, your child’s therapist may be required to share details of their 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 dynamic between the therapist, client, parent or guardian and various other factors. We are committed to providing your child with the most professional and ethical treatment possible.

Participation in therapy can result in a number of benefits to your child, including improved interpersonal relationships, resolution of specific problems, and positive personal change. In order for therapy to be successful, your child will need to make an active effort both during and outside of your sessions. Since therapy often involves discussing unpleasant aspects of life, your child 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 family conflict or other challenges). Change can often happen quickly, but may also occur more slowly. There are no guarantees about what your child will experience. Your therapist’s role is to help guide your child through the therapy process by offering emotional support, actively listening to their concerns, asking relevant questions, providing treatment plans and recommendations, and monitoring their treatment progress.

A parent or guardian must attend the first session. During the first session, you and your child will discuss with the LCA therapist the reasons your child is seeking therapy, goals your child would like to achieve, and any background information related to your child’s presenting concerns. In subsequent sessions, your child and their therapist will work collaboratively towards achieving their 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. Your child’s LCA therapist may, in their professional discretion and subject to state law, request that you join subsequent sessions with your child, or they may request to hold clinical sessions with you alone to discuss how best to support your child’s mental health. 

Throughout therapy, your child will work with their LCA therapist to tailor treatment to meet their goals and assess whether the goals are being met. If at any point you or your child are unhappy about the progress, process, or outcome of the treatment, please discuss this with the therapist. There are many different methods your child’s therapist may use to address the concerns that bring them to therapy. Your child’s therapist strives for genuineness and a nonjudgmental stance in all patient relationships. However, if at any time you or your child feel that your child is not connecting or that the therapist has misunderstood your child in an important way, please discuss your concerns in session with your child’s therapist. In addition, the Lyra Care Navigator Team is always available to work with you and your child, and may also reach out to you to discuss your and your child’s overall satisfaction with the therapy provided to your child.     

Your Therapist’s Credentials. Your child’s 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 child’s 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 child’s therapist know if your child will be traveling to another state or if your child moves to another state. In some cases, therapists are not able to provide services to your child while you are located in another state, even temporarily.

Communication with Parent(s) or Guardian(s): Generally information shared in session is confidential. As permitted by applicable federal and state law, your child’s therapist may share information about your child’s treatment with you. It is best that the process be a collaborative one involving you, your child, and clinician in order to maintain the rapport established between your child and clinician since rapport is vital to treatment success. Trust between your child and their therapist is built when information remains confidential. Therefore, unless there is a safety concern, your child would be consulted about the disclosure and encouraged to share the information with you first in order to establish better communications within the family structure. 

Communication with Other Adults: 

School: Your child’s therapist will not share information with their school unless you and your child provide written permission to allow communication. Sometimes your child’s therapist may want to talk to people at your child’s school who interact with your child and may have information that is valuable for treatment and/or may be able to utilize strategies learned in therapy to help in the school environment. 

Doctors or other care providers: Your child’s therapist will not share information with their doctor or other care providers unless you and your child provide written permission to allow communication, unless otherwise required by state law. Your child’s therapist may need to speak with your child’s doctor or other care provider to confer on your child’s care. 

The Lyra Website: As part of therapy your child will use the Lyra Website. Your child 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 their therapist via secure messaging.

Your child’s therapist will orient your child to using the Lyra Website for the above purposes during the first therapy session. You will not have access to the Lyra account for your child. Once you consent to your child’s treatment, you will be able to contact your child’s therapist by email or the Lyra Care Navigator team. If your child is unable to hold a video session, it is possible to have sessions with your child’s therapist by phone (without using the video option in the Lyra Website); your child’s therapist will call your child at the number provided at registration. Your child will still need to use the Lyra Website to complete assessments and submit records of therapy practices each week.

Therapy Assessments: Before your child’s first session, their therapist will ask them to answer a set of questions that will help them get to know your child and better tailor treatment to respond to your child’s situation. Parents or guardians will also complete assessments that evaluate your child’s progress. You may also provide information in the initial session and during the course of treatment as needed. Throughout therapy, your child’s therapist will assign other assessments to be completed before their sessions to inform treatment.

Therapeutic Focus: LCA therapists do not make recommendations, write letters of recommendation or complete application forms related to items outside the scope of treatment (e.g. medical leave, medical disability, fitness to work, child custody, or emotional support animals).

Video Therapy: Please note that:

  • As part of this program your child will engage in telehealth sessions with their LCA therapist.
  • All telehealth sessions are held by video using the Lyra Website.
  • Your child’s therapist will initiate the video session with your child 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 your child will not be in the same room as their therapist.
  • In order to have the best results for your video session, your child should be in a quiet and private place with limited interruptions when they 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 and their families 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 your child; 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 child or their Lyra therapist can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
  • Your child’s LCA therapist will inform your child and obtain their consent if another person who is not the parent or guardian is present during the session, for any reason. For example, persons may be present during the session other than the LCA therapist in order to operate the telehealth technologies. Your child will be informed of their presence in the session and they will have the right to request the following: (a) omit specific details of their medical history/examination that are personally sensitive to them; (b) ask non-medical personnel to leave the telehealth session; and/or (c) terminate the session at any time.
  • There are alternatives to a telehealth session available, including the option of finding an LCA therapist to see your child in-person.
  • You and your child 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 child’s LCA therapist, and it covers all telehealth sessions your child may have.
  • You or your child can withdraw consent for telehealth sessions in the course of your child’s care at any time for any reason or no reason, without affecting your child’s right to future care or treatment, and Lyra will work with you and your child 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 child’s LCA therapist may decide to terminate telehealth services, if they deem it inappropriate for your child to continue therapy through video sessions. Your child’s LCA therapist will work with other team members to identify another LCA therapist for in-person care.
  • By signing this consent form you agree for you and your child to work with your child’s LCA therapist to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during their sessions.

Video Recording: Your child’s therapist will ask them at the start of each session if they consent to the session being recorded. If your child consents, their therapist will record the session for ongoing quality improvement, quality assurance, training, and development of our services. Video recordings are kept for 2 weeks and then deleted. No one other than the therapist (including you and your child) has permission to record sessions. We may retain some information from the session in a fully de-identified and anonymized format for longer than 2 weeks for ongoing quality assurance, training, and development of our services.

Your Child’s 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 child’s LCA therapist is appropriately licensed, we ask that you and your child please search for a provider based upon your child’s planned location at the time your child’s session takes place. If your child’s location changes at any point from one state to another, please let your child’s LCA therapist know as soon as possible. Please be aware that your child’s LCA therapist may not be able to provide services when your child travels to a different state and is not able to provide services when your child travels outside of the U.S.

Missed Appointments and Cancellations: LCA requires at least 24 hours advance notice for cancellation of an appointment. If your child is unable to attend their scheduled appointment due to circumstances beyond their control, please encourage your child to message their therapist in the Lyra Website as soon as possible so we can reschedule their appointment to a more suitable time. Once an appointment is scheduled, your child will be expected to attend unless they contact their therapist to reschedule. They can also use email to reschedule; however, please note that receiving emails in your child’s personal account may be unsecure. Failure to provide sufficient notice for cancellations and/or repeated no-shows for your child’s appointment may impact their ability to schedule additional appointments with their therapist. If a session is cancelled or rescheduled within 24 hours of a scheduled day/time, or the session is not attended, a $105.00 Cancellation Fee may apply. 

In-Between Session Communication: If your child needs to contact their LCA therapist between sessions, for non-urgent issues, please have your child message them within the Lyra Website. Your child’s therapist checks his/her messages in the Lyra Website regularly during business hours and will make every effort to return your child’s 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 your child is experiencing an emergency. If you or your child would like to speak to someone for support prior to the therapy appointment, or if your child experiences distress prior to the appointment, please use the Lyra Health Care Navigator Team number (877-505-7147) for non-emergency situations. Your child’s Lyra therapist may not be available to respond immediately due to variations in working hours. Your child’s Lyra therapist will respond to messages within 48 business hours of receipt.

If your child experiences an emergency during sessions with their LCA therapist, or if your child’s LCA therapist becomes concerned about your child’s personal safety, the possibility of your child injuring someone else, or about your child receiving proper psychiatric care, your LCA therapist and LCA will do whatever possible within the limits of the law to prevent your child from injuring self or others and to ensure that your child receives the proper medical care. For this purpose, LCA or your child’s LCA therapist may contact a parent, guardian, or other emergency contact listed on the biographical sheet. 

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 child’s LCA therapist will not accept friend or contact requests from current or former clients or their parents/guardians on any social networking site. If you have questions about this, please raise them with your child’s therapist.

Billing and Payments: The fees for your child’s sessions may be partially or fully paid for by you, or your eligible sponsor’s, employer or Health Plan, with or without any cost share to your child, as long as your child is an eligible employee in good standing with the company or eligible dependent, and as long as further sessions are considered clinically appropriate. 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. 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]

Research, Writing, Teaching: Your child’s 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 your child and your child’s treatment may be used to support these initiatives. Any use of information about your child’s 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 child’s course of treatment will be individualized depending on the intensity and duration of your child’s presenting concerns, your child’s level of engagement and active participation in the treatment plan, and the specific nature of your child’s concerns.

Ending Treatment: Your child may withdraw from treatment at any time. Your child’s therapist recommends that your child or you discuss any plans 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 child’s therapist assesses that the sessions are not effective in helping your child reach therapeutic goals, your child’s LCA therapist will discuss this with your child and, if appropriate, end treatment. In such a case, they will work with you and your child and the Lyra Care Navigator Team to identify alternative options.

If your child does not keep their scheduled appointments and does not respond to communications from their therapist, your child’s therapist will assume your child has elected to end treatment and we will close your child’s case. If this occurs, and your child wishes to resume 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 your child is 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 child’s primary care provider may obtain a copy of your child’s records of your child’s telehealth encounter.

This document is intended to provide you with all of the information required by the Board of Professional Counselors which regulates all licensed professional counselors.  You may contact the Board with any questions or concerns.

Board of Professional Counselors

Division of Corporations, Business & Professional Licensing

P.O. Box 110806 Juneau, AK 99811-0806 Phone: (907) 465-2551

Email: [email protected]

Arizona

Your child is entitled to all existing confidentiality protections, including where a provider may only disclose all or part of your child’s medical record and payment record as authorized by state or federal law or written authorization signed by your child or their 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 child’s medical record as defined in A.R.S. § 12-2291.  You also understand dissemination of any images or information identifiable to your child for research or educational purposes shall not occur without your child’s consent, unless authorized by state or federal law.  Ariz. Rev. Stat. Ann. § 36-3602(D).

Board of Behavioral Health Examiners

1740 West Adams Street, #3600

Phoenix, AZ 85007

Main Number: 602-542-1882

Fax Number: 602-364-0890

[email protected]

Colorado

If you have a concern or complaint about the mental health professionals providing care to your child, you may contact a board agency to assist you. You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4.  The confidentiality of your child’s 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.

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 your child whether they consent to that provider’s disclosure of records concerning the telehealth interaction to your child’s primary care provider.  You further understand that your child’s primary care provider may obtain a copy of your child’s records of their telehealth encounter, upon their consent. Conn. Gen. Stat. Ann. § 19a-906(d).

Connecticut Department of Public Health

Professional Counselor Licensure

410 Capitol Ave., MS #12 APP

P.O. Box 340308

Hartford, CT 06134

Phone: (860) 509-7603

Fax: (860) 707-1980

Email:  [email protected]

District of Columbia

Your child has been informed of alternate forms of communication between your child 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 child’ s medical record. D.C. Mun. Regs. tit. 17, § 4618.9.

Professional Counseling Licensing

899 North Capitol Street, NE, Washington, DC 20002

Phone: (202) 442-5955

Fax: (202) 442-4795

Georgia

Your child has been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. Ga. Comp. R. & Regs. 360-3-.07(a)(7).

GA Board of Professional Counselors, Social Workers, and Marriage and Family Therapists

214 State Capitol

Atlanta, Georgia 30334

Idaho

You understand that you and your child’s 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

Illinois

If you need to register a formal complaint about a professional regulated under the Illinois Division of Professional Regulation, you may file a formal complaint here: https://www.idfpr.com/admin/DPR/DPRcomplaint.asp 

Chicago: 555 West Monroe St., 5th Floor Chicago, IL 60661

Springfield: 320 W. Washington Street, 3rd Floor, Springfield IL

Phone: 1 (888) 473-4858

Indiana

If you have a concern or complaint about the non-physician mental health professionals providing care to your child, you may contact a board agency to assist you. You may file a complaint here: https://www.in.gov/pla/file-a-complaint/

Indiana Professional Licensing Agency

402 W. Washington St., Room W072

Indianapolis, Indiana 46204

Staff Phone Number: (317) 234-2054

Staff E-mail: [email protected]

Agency Fax: (317) 233-4236

Iowa

If you have a concern or complaint about the non-physician mental health professionals providing care to your child, you may contact a board agency to assist you. You may find information related to filing a complaint here: https://idph.iowa.gov/Licensure/Iowa-Board-of-Behavioral-Science

  

Kansas

You understand that if your child has a primary care or other behavioral health treating provider and if your child consents to us sharing their 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 LCA 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

Kansas Board of the Healing Arts

800 SW Jackson, Lower Level – Suite A, Topeka, KS 66612

(785) 296-7413; Fax (785) 368-7102

Kentucky

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here:

https://kbml.ky.gov/board/Pages/default.aspx.

Information related to filing grievances may be found here: https://kbml.ky.gov/grievances/Documents/Information%20on%20Filing%20A%20Grievance.pdf

  

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 North Suite A

Baton Rouge, LA 70816

225-295-8444 (phone)

225-295-8448 (fax)

[email protected]

Maine

If you have a concern or complaint about the mental health professionals providing care to your child, 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

www.maine.gov/professionallicensing

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.

  

Nebraska

If your child is a Medicaid recipient, your child retains the option to refuse the telehealth consultation at any time without affecting their 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. Your child shall have access to all medical information resulting from the telehealth consultation as provided by law for access to their medical records.

Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without you and your child’s written consent. You understand that your child has the right to request an in-person consult immediately after the telehealth consult and your child 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

Lincoln NE 68509-4986

Complaints: https://dhhs.ne.gov/Pages/Complaints.aspx

New Hampshire

You understand that the provider may forward your child’s medical records to their primary care or treating provider.  N.H. Rev. Stat. § 329:1-d.

Office of Professional Licensure & Certification

7 Eagle Square

Concord NH, 03301

Phone: 603-271-2152

New Jersey

You understand that your child has the right to request a copy of their medical information and you understand your child’s medical information may be forwarded directly to their primary care provider or health care provider of record, or upon you or your child’s request, to other health care providers. N.J. Rev. Stat. Ann. § 45:1-62.

Professional Counselors Examiners

[email protected]

(973) 504-6582

Ohio

You understand that the provider may forward your child’s medical records to their primary care or treating provider. Ohio Admin. Code 4731-11-09(C).

  

Oklahoma

The licensing website is www.ok.gov/behavioralhealth where you can access the laws and regulations that govern the practitioner’s license. The practitioner will furnish you with printed materials about the requirements of his/her licensure if you so desire.

You may contact (without giving your name), the State Board of Behavioral Health Licensure at:

State Board of Behavioral Health Licensure 3815 North Santa Fe, Suite 110, Oklahoma City, OK 73118 Telephone: (405) 522-3696

Oregon

If you have a concern or complaint about the mental health professionals providing care to your child, 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

The Board of Licensed Professional Counselors and Therapists 3218 Pringle Rd SE, #120,

Salem, OR 97302-6312

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 your child, you may contact a board agency to assist you.

You also understand that you may be asked to confirm your and your child’s 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, Harrisburg, PA 17105-2649 717-783-1389

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 child’s mental health practitioner is also mandated by standards – through Duties to Warn – to breach confidentiality if: (1) your child is threatening self-harm or suicide; (2) your child is 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.

You also understand that if your child is a Medicaid beneficiary, your and your child 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,

Columbia, South Carolina 29211-1329 Telephone: 803-896-4652

Tennessee

You understand that your child may request an in-person assessment before receiving a telehealth assessment if your child is a telehealth recipient.

The information your child shares 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 child’s 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

Nashville, TN 37243

[email protected]

Texas

You understand that your child’s medical records may be sent to their primary care physician. Tex. Occ. Code Ann. § 111.005.

See column to left.

Utah

You understand (i) the fees that may be charged to you for the telehealth service; (ii) to whom your child’s health information may be disclosed and for what purpose, and have received information on any consent governing release of your child’s patient-identifiable information to a third-party; (iii) your child’s rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You were warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of LCA’s website and contact information. You understand that you are able to select a provider of your child’s choice, to the extent possible. You are able to select a pharmacy of choice. Your child is able to a (i) access, supplement, and amend their patient-provided personal health information; (ii) contact their provider for subsequent care; (iii) obtain upon request an electronic or hard copy of their medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of their medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.

  

Vermont

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 and your child surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your child’s needs. RCW 18.19.060.

The information your child shares 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.

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

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

Cheyenne, WY 82002

Tel: (307) 777-3628

Fax: (307) 777-3508

[email protected]

TREATMENT AGREEMENT

If at any time you have questions about the details above, please ask your child’s therapist or the Lyra Care Navigator Team. As therapy continues with your child and their therapist, you accept and agree to abide by the contents and terms of this agreement and consent to participate in your child’s evaluation and/or treatment.