CONSULTATION FORM
Free Initial Consultation

Thank you for taking the first steps towards improving your overall mental health and well-being! We are delighted that you would like to learn more about eTherapy to see if this service is right for you.

Before you can become a Synergy eTherapy client, one of our licensed therapists will speak with you over the phone to explain our services and go over the privacy and security policy as well as the online clinic policy.

*Please note:

You must be a resident of the same state that the therapist is licensed.

Currently, our therapists are licensed to work in: Minnesota, New York, and Wisconsin

Once this first step is completed and approved, you will be given access to our “Client Login” page to purchase services, gain access to your therapist’s calendar to schedule future appointments, pay for services using a credit card, receive important links to meet your therapist in their video chat room and get access to a secure texting app in order to maintain private communication with your therapist.

We will get back to you within 24 hours. Thank you!

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Synergy eTherapy Privacy Policy & Informed Consent

(Last updated 3/5/17)

The Privacy and Online Clinic Policies are here to protect both You (“User” or “Client”), Synergy eTherapy (“Company”) and each Independent Therapist when engaged in an initial eTherapy consultation and every subsequent eTherapy clinical service. The following content must be read, discussed with your therapist at the initial consultation (and any time thereafter as needed), and agreed upon before the client-therapist relationship can begin. Please make sure to read each section carefully. If you have any questions, please discuss them with your therapist before purchasing any eTherapy services. Synergy eTherapy reserves the right to change the terms of this notice and to make any new provisions effective for all protected health information that we maintain. Please feel free to print a copy of this policy for your records or we can send you a copy if requested.

Privacy & Security of eTherapy services

Privacy and confidentiality are of utmost importance to Synergy eTherapy and to each independent therapist in this group practice. Although no transmission of data can be 100% secure, Synergy eTherapy takes reasonable steps to ensure that your information is kept private and secure. For people seeking mental health counseling, it is important to know that your Protected Health Information (PHI) is kept safe. PHI is any information that can identify you. We strictly abide by our codes of ethics as well as by the laws governed at the state and federal levels. The Health Insurance Portability and Accountability Act (HIPAA) contains privacy and security rules that are designed to be a minimum level of protection for your PHI. Privacy rule gives you the right to your medical information and sets limits on who else has access to your PHI. The Security rule is a federal law that ensures that your PHI is in electronic form and secure. https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

For those entities that store your PHI with whom Synergy eTherapy contracts and that company is not under the HIPAA umbrella of covered entities (such as, but not limited to, the email provider, online video chat company, and credit card merchant), a Business Associate Agreement (BAA) was obtained to ensure that the PHI will be appropriately safeguarded. https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html

Synergy eTherapy may use your PHI for treatment, payment and eTherapy operations purposes with your consent for the following services:

    1.   Initial Contact and Consultation:
  • a.   A prospective client (or user) will complete a contact form on the website that will include basic demographic PHI. This information is not stored on the server and will go directly to a HIPAA secure Synergy eTherapy email address in order for a therapist to follow up with you at a later time.
  • b.   During an initial consultation, your therapist will collect additional PHI to help determine if eTherapy is right for you. This information will be stored in a HIPAA compliant secure document for information gathering purposes and future follow-up.
  • c.   A user can choose to receive monthly email newsletters. Your email address will be used for sending these free electronic resources to you from Synergy eTherapy. You can opt-out of the newsletter at any time. Synergy eTherapy will not sell or provide your email to any other entity.
  • d.   Synergy eTherapy has a professional Facebook and Twitter Account. You can choose to “Like” and/or “Follow” us at your discretion. We will, at no time, engage in conversation with an established client in these social messenger apps.
    2.  Treatment:
  • a.   A client-therapist relationship only begins after the initial consultation is completed, the user agrees to these privacy and online clinic policies, payment is received, an appointment is scheduled, and your first eTherapy session is completed.
  • b.   PHI gathered from your eTherapy sessions are stored in a secure online Electronic Medical Record system.
  • c.   No outside entity will get access to any client’s PHI without a formal Release of Information (ROI) signed by the client (or legally approved representative, such as a parent/guardian of a minor client) for purposes of collaboration with family members or external providers to coordinate care.
    3.  Payment:
  • a.   Only your email address, last 4 digits of your credit card and credit card expiration date are stored on the Synergy eTherapy SSL website. Your email address will be used for purposes of sending receipt of payment along with links to schedule subsequent sessions. No other information will be saved that could identify you. Please see below on how to create a separate email address to use solely for the intended purpose of eTherapy correspondence.
  • b.   Stripe is the merchant used for credit card payments and they are not a covered entity, meaning they are not required to comply with HIPAA rules and regulations. To learn more about Stripe’s Privacy Policy, click here https://stripe.com/us/privacy
    4.  eTherapy Operations:
  • a.   All therapists within the Synergy eTherapy group practice are able to collaborate and consult with one another and retain the right to share a client’s PHI for purposes of providing the best clinical care possible.
  • b.   Synergy eTherapists are also able to share a client’s PHI in order to send/receive referrals to one another for more appropriate matching of client and therapist.
  • c.   Synergy eTherapy never rents, sells or gives your PHI information to a third party without a signed ROI from you or your legally-approved representative (including a minor’s parent/guardian).
  • d.   Synergy eTherapy uses Google Analytics for gathering user information and browsing experience on our website. This information is anonymous and has no connection to any individual PHI. To learn more about Google Analytics Terms and Privacy click here https://www.google.com/policies/privacy/ and to opt out of Google Analytics go to https://tools.google.com/dlpage/gaoptout/

Risks Associated with eTherapy

There are always potential security risks associated with electronic communications over the Internet or cellphones as the web and cellphones may not be 100% secure. It is the responsibility of Synergy eTherapy, each independent therapist, as well as you, the client, to ensure confidentiality is maintained. Here are some tips to help you safeguard your information:

  • Use your own personal computer instead of a work computer and create complex passwords to protect email correspondence from being seen by others. Do the same for your cell phone. Pay attention to where you store your cell phone when you are not using it as notifications of emails or texts may pop up where others could see your private information.
  • With eTherapy phone or video sessions, always find a private space to engage in your session so that conversations are not overheard by others. Use headphones or Bluetooth devices so others cannot hear the conversation.
  • Install a “Firewall” and maintain updated anti-virus protection on your computer. You can also create a Hushmail (http://www.hushmail.com/) or other separate email account that you can use just for eTherapy to ensure extra confidentiality and security.

Mandated Reporting

Since every therapist at Synergy eTherapy is a mandated reporter, we do not need your consent to release PHI to a local supervising agency if we learn about or suspect possible abuse or endangerment to yourself or others. State statutes require persons in designated professional occupations to report suspected endangerments of self or others. This means that if certain topics are reported over the course of any eTherapy correspondence (including but not limited to phone, video, text, email), your therapist is required to report that information to a local supervising agency. These disclosures include:

  1. The report of any neglect, endangerment, verbal abuse, physical abuse, or sexual abuse to a child.
  2. The report of neglect, endangerment, verbal abuse, physical abuse, or sexual abuse of any vulnerable adult (persons with developmental issues, elderly, etc.).
  3. The report of intent to hurt or kill yourself.
  4. The report of intent to harm another person with a duty to warn the other party.
  5. A court order for records.

Synergy eTherapy “Clinic” Policies

Patient’s Rights

The Minnesota Bill of Rights for Patients can be found here: http://www.health.state.mn.us/divs/fpc/consumerinfo/mn_pts_rights_eng_reg.pdf

  • * Right to Plan - You have the right to know your treatment options, be a part of your treatment plan, and easily understand information about eTherapy and services provided.
  • * Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.
  • * Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in our mental health records used to make decisions about you for as long as the PHI is maintained in the record.
  • * Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
  • * Right to a Paper Copy - You have the right to obtain a paper copy of the notice upon request, even if you have agreed to print a copy of the notice electronically.
  • * Right to Respect and Non-Discrimination - You have the right to considerate, respectful care from your therapist that does not discriminate against you.

Cancellation Policy

One service may be purchased at a time, which allows you, the client and your therapist to choose how much and how often to engage in eTherapy. Since appointment times are reserved exclusively for you, we ask that if your scheduled time slot for phone or video chat does not work for you, to please contact your therapist directly at least 24 hours before the session start time to have the option to reschedule a service already purchased without penalty.

We understand that life gets busy! Because of the flexibility of eTherapy services, if you are late to your scheduled session (late means entering your session before it is halfway over), you will receive your service for the remainder of your scheduled session time slot without refund. However, your therapist has the right to stop waiting for you after the halfway point of your session if they do not hear from you in any manner. If you do not show up (e.g., you do not check in for a video chat or answer a phone call for a phone session) at the time of a scheduled session, nor did you contact your therapist within the 24 hour cancellation window to reschedule, this is considered a “no show” and you may not be allowed to reschedule that session. Once a service is purchased and the session time missed, there are no refunds for that session. If several “no shows” occur, you and your therapist can discuss alternative options for treatment that may work better for you.

Questions and Complaints

If you have questions about this notice, disagree with a decision Synergy eTherapy has made about access to your records, or have other concerns about your privacy rights, or believe that your privacy rights have been violated and wish to file a complaint with our office, you may call or email your written complaint to Dr. Lisa Herman, Psy.D., Licensed Psychologist and Owner of Synergy eTherapy, at (612) 642-1355 [email protected]

You have specific rights under the Privacy Rule. Synergy eTherapy will not retaliate against you for exercising your right to file a complaint.