Consent for Neuropsychological Assessment

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

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 providers 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 providers 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 providers 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 providers 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 provider’s judgment, your child is in danger of harming themself or another person.
- If your child communicates to their provider a serious threat of physical violence against another person.
If your child’s provider is ordered by a court to release information as part of a legal proceeding, your child’s provider may be required to share details of their care.
As otherwise required by law and/or detailed in our Notice of Privacy Practices

Evaluation Nature and Purpose of Assessment: A Clinical Intake is a comprehensive history of an individual’s developmental and overall brain functioning. The purpose of the evaluation is to gather information on the patient’s history. All the information gathered will be used to determine your child’s appropriateness for Neuropsychological Testing Services through LCA.

A neuropsychological evaluation is a comprehensive assessment of an individual’s overall brain functioning by examining cognitive domains, including intellectual functioning, language, memory, non-verbal skills, and executive skills (attention, inhibition, working memory, processing speed, planning and reasoning, and organization). In addition to the 1:1 work investigating the individual’s neurocognitive abilities, neuropsychological evaluations also include completing rating forms to understand better the individual’s day-to-day functioning and interviews that may cover topics such as medical history, general background, academics, and social functioning. The result of the evaluation is to provide insight into the functioning of the patient, make a diagnosis when appropriate, and provide recommendations. All the information gathered will be included in a report, generally made available to the minor’s parent / legal guardian. If state or federal law grants the minor confidentiality rights over these records, we may only disclose the information in accordance with those laws or with the minor’s written authorization.

Procedure: Your child’s Clinical Intake will occur in one video session. Once the evaluation has been completed, the team will meet to discuss the appropriateness of services.

Your child’s evaluation may occur in one or more video sessions. A parent or guardian must attend the first session. Your child’s provider 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. Once all the testing and interviews have been completed (and if your child’s evaluation includes outside rating forms, once these are also received), a report will be completed that will discuss the findings, provide a diagnosis if appropriate, and provide recommendations (unless otherwise stated such as in the case of school admissions testing). A feedback session will be offered to the family to review the results and recommendations and allow you and your child to ask any questions that you may have, unless applicable law limits family participation.

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

Communication with Other Adults:

School: Your child’s provider will not share information with their school unless you and your child provide written permission to allow communication. Sometimes your child’s provider 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 treatment to help in the school environment.

Doctors or other care providers: Your child’s provider 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 provider 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 the evaluation you and/or your child may use the Lyra Website. You and/or your child may need to access the Lyra Website to participate in the video sessions, submit intake paperwork and other information between sessions, as well as to connect with their provider via secure messaging.

If your child is 13 years old or older, 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 provider by email or the Lyra Care Navigator team.

Treatment Focus: LCA providers 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 Sessions: Please note that:

As part of this program your child will engage in telehealth sessions with their LCA provider.
All telehealth sessions are held by video using the Lyra Website.
Your child’s provider 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 provider due to the fact that your child will not be in the same room as their provider.
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 provider 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 provider 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 provider can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
Your child’s LCA provider 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 provider 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 a provider to see your child in-person.
You and your child can direct questions about your telehealth sessions at any time to your LCA provider or Lyra Care Navigator Team member.
This consent will last for the duration of the relationship with your child’s LCA provider, 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 provider may decide to terminate telehealth services, if they deem it inappropriate for your child to continue treatment through video sessions. Your child’s LCA provider will work with other team members to identify another provider for in-person care.
By signing this consent form you agree for you and your child to work with your child’s LCA provider 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 LCA provider will ask you and your child (when you are both present) or just your child (when only the child is present) at the start of each session for consent to the session being recorded. If consent is given, your child’s LCA provider 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 child’s LCA provider prior to inclusion in the clinical record.

Video recordings are retained in accordance with Lyra’s privacy practices. No one other than your child’s LCA provider (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.

Some or all portions of your child’s neuropsychological evaluation may be video recorded. Recordings are used for the purpose of ensuring the quality and accuracy of the evaluation process, including the neuropsychologist’s review of testing procedures and behavioral observations.

You and your child have the right to decline video recording without any impact on your ability to receive services. However, declining may limit the provider’s ability to review certain aspects of your child’s performance and behavior, which can be helpful in completing a thorough assessment.

Your Child’s Location During Video Sessions: Like all health care providers, LCA’s providers are licensed to offer services on a state by state basis. In order to ensure your child’s LCA provider 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 provider know as soon as possible. Please be aware that your child’s LCA provider 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 provider 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 provider 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 provider. If a session is cancelled or rescheduled within 24 hours of a scheduled day/time, or the session is not attended, a $200.00 Cancellation Fee may apply.

In-Between Session Communication: If your child needs to contact their LCA provider between sessions, for non-urgent issues, please have your child message them within the Lyra Website. Your child’s provider 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 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 provider may not be available to respond immediately due to variations in working hours. Your child’s Lyra provider will respond to messages within 48 business hours of receipt.

If your child experiences an emergency during sessions with their LCA provider, or if your child’s LCA provider 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 provider 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 provider may contact a parent, guardian, or other emergency contact listed on the biographical sheet.

Social Media Policy: LCA and our providers 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 provider 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 provider.

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 provider 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.

Ending Treatment: Your child may withdraw from the evaluation at any time. Your child’s provider recommends that your child or you discuss any plans to end the evaluation with them before taking action, so that they have an opportunity to offer further recommendations or referral options.

If your child does not keep their scheduled appointments and does not respond to communications from their provider, your child’s provider will assume your child has elected to end the evaluation and we will close your child’s case. If this occurs, and your child wishes to resume an evaluation, please contact the Lyra Care Navigator Team to reinitiate services.

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]
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.	Board of Behavioral Sciences 1625 North Market Blvd., Suite S200 Sacramento, CA 95834 www.bbs.ca.gov Phone: (916) 574-7830
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 provider or the Lyra Care Navigator Team. As treatment continues with your child and their provider, 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.