Welcome. To begin your counseling journey this form will
provide you with information on my credentials, the process of
counseling, confidentiality, emergencies, and other details about
your treatment. At any time during your treatment, please
feel free to ask any clarifying questions.
Ms. Speakman's Credentials
License: Licensed Mental Health Counselor #MH12401
Link to verify my license:
http://floridasmentalhealthprofessions.gov/
Credentialing: Distance Credentialed Counselor (DCC)
Certifications: National Certified Counselor (NCC), Certified
Clinical Mental Health Counselor (CCMHC), Professional Florida
Educator Certification in Guidance and Counseling
(Pre-Kindergarten-12), Specific Learning Disabilities (K-12), and
Elementary Education (K-6)
Client's participation - Expectations of the client:
The client should -
} Avoid using mind altering substances prior to session
} Dress appropriately
} Hold the session in an appropriate room (not a bedroom)
when attending a web-based session
} Do not have anyone else in the room unless you first
discuss it with your counselor
} Not conduct other activities while in session, such as
driving
} Not bring any weapons of any kind to session (based upon
clinical judgment)
} Do not record sessions without first obtaining the
provider's approval.
} Be located within the states in which the clinician is
licensed to practice (client should inform the clinician of their
location)
Confidentiality and Records
All of your PHI, protected health information, is kept for a
minimum of five years.
It is my personal, professional, and legal obligation to keep all
of your protected health information (PHI) confidential, with
some exceptions. The Notice of Privacy Practices form on
https://clinicalcounselingsolutions.securepatientarea.com/ (which
you are asked to sign) provides detailed information about how
private information about your health care is protected, and
under what circumstances it may be shared.
Other than the exceptions listed on the Notice of Privacy
Practices form, I, Waynette Speakman,will be the only person
viewing your information.
If you make payments via credit card there is the possibility
that you may receive an email receipt, and the payment will show
on your billing statement.
The following information explains how I handle and store your
PHI while you are receiving counseling if you chose any of the
following counseling modalities. Although it is not
guaranteed that these methods will prevent 100% of
confidentiality breaches, they are designed with the intention of
supporting the confidentiality of all clinical communications:
Face-to-face:
Face-to-face sessions in my office are provided behind a closed
door.
Your information is stored via Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/)
which is HIPAA compliant and provides a BAA. Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/) uses
point-to-point, federal approved, encryption.
The only information of yours that is stored on any electronic
device of mine is your phone number (on my phone), and your email
address (on my computer), if you have emailed me.
My phone and computer are both password protected.
Any paper with your personal information is kept in a locked
cabinet behind a locked door.
Email:
All email correspondences will be done through the Counsol secure
website
(https://clinicalcounselingsolutions.securepatientarea.com/),
unless you request otherwise.
The Counsol website
(https://clinicalcounselingsolutions.securepatientarea.com/)
stores our email correspondence, but is it encrypted.
Chat:
All chat correspondences will be done through Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/),
unless you request otherwise.
Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/)
stores our chat correspondence, but is it encrypted.
Video Conferencing:
All video conferencing correspondences will be done through
Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/),
which is encrypted to the federal standard.
Texting:
All texting correspondences will be done through Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/),
which is encrypted to the federal standard.
Client's Responsibilities / Client's
Protection
If you use any other methods of electronic communication with me,
Waynette Speakman, there is a reasonable chance that a third
party may be able to intercept that communication.
With the use of technology it is important to be aware that
family, friends, co-workers, employers, and hackers may have
access to any technology, devices, or applications that you
use.
I encourage you to only communicate through a computer, or any
other device, that you know is safe, and to follow the safety
measures that are detailed on the Counsol secure website
(https://clinicalcounselingsolutions.securepatientarea.com/). You
are responsible for reviewing the privacy settings and agreement
forms of any applications or technology you use.
Please contact me with any questions that you may have on privacy
measures.
Contact information
When you need to contact me for any reason, these are the most
effective ways to get in touch in a reasonable amount of time:
} By phone 813-609-2620. You may leave messages on the
voicemail, which is confidential.
} By email using your client portal on Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/).
Please refrain from making contact with me using any social media
messaging systems such as Facebook Messenger or Twitter. These
methods have very poor security and I am not prepared to watch
them closely for important messages from clients.
Please refrain from creating reviews of my services online.
Online reviews are for the public to see and therefore they would
put your confidentiality at risk.
Any text based communication may become part of your record.
Response Time
I may not be able to respond to your messages and calls
immediately. For voicemails and other messages, you can
expect a response within 24 hours on weekdays, and 72 hours on
weekends. Be aware that there may be times when I am unable to
receive or respond to messages, such as when out of cellular
range or out of town.
Emergency Contact
If you are ever experiencing an emergency, including a mental
health crisis, please call 911, Lifeline 1-800-273-8255, or go to
your nearest emergency room.
If you need to contact me about an emergency, the best method is:
} By phone 813-609-2620
} If you cannot reach me by phone, please leave a
voicemail.
Couples Counseling
In the process of couples counseling, I, your therapist, do not
keep secrets for any party.
Cost of Sessions
The cost of your session will be agreed upon between you and I
over the phone. It will also be stated on your scheduled
appointment on your client portal on Counsol
(https://clinicalcounselingsolutions.securepatientarea.com/).
The cost of the session depends on the counseling medium used,
the date, the time, and any financial hardship that you may
have.
You, the client, are responsible for the cost of any technology
at your location, such as a computer, device, phone, phone call
charges, software, and headset.
If you are in need of additional support between sessions and
choose to use telephone calls, email or chat, you will be billed
$1 per minute for every minute that exceed 10 in duration.
Email counseling is billed at $40 per email that you send with a
maximum of 300 words per email. You will get one email
response per email that you send.
Most insurance providers will not cover distance
counseling. Some insurance carriers will cover distance
counseling via video conferencing, within their given parameters.
PAYMENT FOR SERVICE: Clients are expected to pay fees at
the time services are rendered. Please notify Ms. Speakman
if any problem arises regarding your ability to make timely
payments. Fees are set in accordance with the type and
extent of services that are conducted. If payment is
not received within 90 days, or monthly payments are not made as
agreed, Ms. Speakman may submit the invoice to an attorney or
collection agency.
INSURANCE REIMBURSEMENT: Clients who carry insurance should
remember that professional services are rendered and charged to
the client and not to the insurance company. You will be
provided with a receipt that you can submit to your insurance
company for reimbursement. If the insurance company
requires forms to be completed, be certain to give them to Ms.
Speakman at your earliest convenience. In instances where
extraordinary professional time is required, you may incur
additional fees.
The receipt of payment may also be used as a statement for
insurance if applicable to you. There is a $25 fee for any
returned checks. If you pay by credit card you might receive a
receipt via email, and it will likely show up on your billing
statement.
By not canceling your appointment as stated in the cancellation
policy, you are agreeing to the price of your session as stated
on Counsol
(https://clinicalcounselingsolutions.securepatientarea.com).
The cost for documentation requested, and appearing in court
depends on the specific request.
Cancellation Policy
Since the scheduling of an appointment involves the reservation
of time specifically for you, a minimum of 24-hours notice is
required for rescheduling or canceling an appointment. The
full fee may be charged for missed sessions without such
notification.
Structure of Sessions
I, Waynette Speakman, offer counseling via face-to-face, video
conferencing, phone, chat, and email. Distance counseling
is considered any of those methods other than face-to-face.
If your counseling need is appropriate for distance counseling,
you can either solely receive counseling via one medium, or any
combination of them.
Face-to-face sessions are held at the following location:
My office: 6601 Memorial Highway, Suite #312, Tampa, FL,
33615
Video conferencing counseling sessions are held
via
(https://clinicalcounselingsolutions.securepatientarea.com/portal/index/).
It is recommended that you sign on to your (technology provider
name/web address) account at least 5 minutes prior to you session
start time. You are responsible for initiating the
connection with me at the time of your session.
Chat
Sessions (https://clinicalcounselingsolutions.securepatientarea.com/portal/index/).
It is recommended that you sign on to your account at least 5
minutes prior to you session start time. You are
responsible for initiating the connection with me at the time of
your session. You are responsible for initiating the
session.
Email sessions are provided via
(https://clinicalcounselingsolutions.securepatientarea.com). You
simply email me, and within two days you will get a response from
me. Since you are billed per email that you send (max of
300 words per email), it is recommended that you spend time
thinking about your emails prior to sending them.
If sessions are requested via phone, texting, email, or chat you
will have to have a brief interaction either face-to-face, or via
video conferencing in order to verify your identity by matching
you with your picture ID. During this initial verification
you will choose a passphrase or number which you will used for
all future sessions. This process protects you from another
person posing as you.
Whenever there is communication that lacks visual or audio cues
there is a risk of misunderstanding. When this happens it
is important to assume that your counselor has positive regard
for you, and to check out your assumptions. This will
reduce any unnecessary hardship.
If at any time you do not have internet access at your home, or
private location you can contact me via phone to help you locate
internet service (if available) that will be appropriate for
distance counseling.
Limitations of Distance Counseling
Distance counseling should not be viewed as a substitute for
face-to-face counseling or medication by a physician. It is
an alternative form of counseling with certain limitations.
By signing this document you agree that you understand that
distance counseling:
} may lack of visual and/or audio cues, which may cause
misunderstanding.
} may have disruptions in the service and quality of the
technology used.
} may not be appropriate if you are having a crisis, acute
psychosis, or suicidal or homicidal thoughts.
} When using email, chat, or texting, there might be a
delay in your counselor receiving your message or they might not
ever receive it.
Emergency Management for Distance Counseling
So that I am able to get you help in the case of an emergency and
for your safety, the following are important and necessary.
In addition, by signing this agreement form you are acknowledging
that you understand and agree to the following:
} You, the client, will inform me, your therapist, of the
location in which you will consistently be during our sessions,
and will inform me if this location changes.
} You, the client, will identify, on your client
information form, a person, whom I, your therapist, am allowed to
contact in the case that I believe you are at risk.
} Depending on my assessment of risk, you, the client, or I
your therapist, may be required to verify that your emergency
contact person is able and willing to go to your location in the
event of an emergency, and if I deem necessary, call 911 and/or
transport you to a hospital. In addition, I may assess, and
therefore require, that you create a safe environment at your
location during the entire time that you are in treatment with
me. This may mean disposing of all firearms and excess
medication from your location.
Backup Plan in Case of Technology Failure
The most reliable backup is a phone. Therefore, it is
recommended that you always have a phone available and that I,
your therapist, know your phone number.
If you get disconnected from a video conferencing, chat, or
texting session, end and restart the session. If you are
unable to reconnect within five minutes call me. If I do
not hear from you within ten minutes you agree (unless you
request otherwise) that I can call you on the phone number you
provide on the client information form.
If you are on a phone session and your phone disconnects call me
back, or contact me to schedule another session. If I do
not hear from you within ten minutes you agree (unless you
request otherwise) that I can call you on the phone number you
provide on the client information form. If this happens as
a result of my phone or phone service, and we are not able to
reconnect, you will not be charged for the session.
Termination Policy
I will make two phone calls, leave you two messages, and send you
a letter via certified mail.
CONFIDENTIALITY
All information disclosed within sessions is confidential and may
not be revealed to anyone without written permission except where
disclosure is required by law. Disclosure may be required
under the following circumstances: Where there is a
reasonable suspicion of child or elder adult abuse. Where
there is reasonable suspicion that the client presents a danger
of violence to others or where the patient is likely to harm him
or herself unless protective measures are taken. Disclosure
may also be required pursuant to a legal proceeding.
Please check the ways in which you are authorizing me to begin
treatment with you:
In-Person
Video
Conferencing
Telephone
Texting
Chat
Email
You may, at any time during the course of your treatment,
withdraw you authorization to any of these modes of treatment
and/or this agreement form as a whole. Simply contact me by
phone, email, or mail.
I acknowledge that I have reviewed the Notice of Privacy
Practices which provides a description of information uses and
disclosures and by signing below you acknowledge that you agree
that you have read and understood this agreement form and agree
to accept mental health services by, Waynette Speakman.
Client Name:
_______________________________
Client Signature:
_____________________________
Date: ________
Signature for legal guardian and or POA:
Legal Guardian/POA Name: _____________________
Legal Guardian/POA Signature: _____________________
Date: ________
