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 Synergy eTherapy to see if this service is right for you.

First, we will engage in a FREE initial consultation. This allows one of our licensed therapists to learn more about what you are experiencing at this time and explain how eTherapy could benefit you or a loved one.

Currently, our therapists are licensed to work with people who reside in the following states: 

Minnesota, Wisconsin, South Carolina, Alabama, Nevada and New York

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

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Synergy eTherapy Privacy Policy & Informed Consent

(Last updated 3/10/18)

Privacy & Security of eTherapy services

This Synergy eTherapy Privacy Policy and Informed Consent form is intended to inform you about Synergy eTherapy’s policies and procedures and to confirm your agreement to the services. By signing this form you, the client, will be acknowledging that you understand and agree that Synergy eTherapy and its provider(s) will provide therapy to you according to this Synergy eTherapy Privacy Policy and Informed Consent form. 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 obtaining any eTherapy services. Synergy eTherapy reserves the right to change the terms of this form 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 an additional copy if requested. This document is found on the Synergy eTherapy website in several locations including your account dashboard and your consent is gathered when you accept the “agree to terms privacy policy” check box before you pay for each eTherapy session.

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 and that describes your health care. 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. The Privacy rule gives you the right to your medical information and sets limits on whom 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).

Synergy eTherapy uses several entities to store and transmit your PHI and to provide communication and financial services related to the services we provide to you. Those entities include, for example, our Internet Company and financial merchant. Those entities that are not “covered entities” according to HIPAA do not require a Business Associate Agreement (BAA). Other companies we use such as the video chat provider, texting app and email do provide Synergy eTherapy with a BAA to ensure that your PHI is protected according to HIPAA requirements. For more information about the Business Associate Agreements, see this link: 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:

    Initial Contact and Consultation:
  • 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.
  • 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.
  • A user can choose to receive monthly email newsletters. Your email address will be used for sending these free electronic resources to your email address 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.
  • Synergy eTherapy has professional social media accounts (i.e., Facebook). You can choose to “Like” and/or “Follow” us at your discretion. We will, at no time, engage in any way that could be considered “treatment” with a user in these social messenger apps. Do not post your PHI on social media in any way.
    Treatment:
  • A client-therapist relationship only begins after the user agrees to this privacy policy and informed consent
  • No outside person or entity will gain access to any client’s PHI unless a) we receive 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, for example, collaboration with family members or external providers to coordinate care, b) we are subject to a court order or subpoena to disclose the PHI, or c) we are under some other legal obligation to disclose the PHI, c) if an investigation is being conducted by a licensing board or other government entity, we may have to disclose information as directed by that board or entity, or d) if there is another federal or state law that requires us to disclose information in other circumstances, we may have to disclose the information to the extent required by that law. (This list is not exhaustive; there may be other situations in which we may have to disclose information about the services we are providing even if you do not want us to do so).
  • Synergy eTherapy uses a calendar system “Calendly” that is not HIPAA compliant. You can choose to fill out your name and email address so that you can get session reminders or you can opt-out of using this calendar system and set up appointments by contacting your eTherapist directly via phone, email or secure text.
  • It is advised not to send PHI over email. Although Synergy has a BAA with Gsuite and information coming in (or at rest) is protected, we cannot guarantee that an email sent back to you on your server will be private and secure. Synergy eTherapy and your therapist will not send PHI to your email unless verbal permission is granted by you, the client. It is up to you whether you wish to send PHI over email to your eTherapist.
  • PHI gathered from your eTherapy sessions is stored in a secure online Electronic Medical Record system.
  • Synergy eTherapy uses a HIPAA compliant phone and text app for you to leave secure and private voice mail messages and text messages. You can choose whether or not you would like to use this app.
    Payment:
  • Only the email address you give Synergy, the 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.
  • 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
    eTherapy Operations:
  • 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.
  • 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.
  • 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).
  • 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/

Mandated Reporting

It is our policy to safeguard the privacy of your PHI and records to the fullest extent permitted by law. However, in some circumstances, we may be required to disclose your PHI and/or records to other people even if you have not authorized us to do so. Examples of situations in which we may have to make such disclosures include, but are not limited to:

  • If we receive information from you, the client or others indicating that abuse or neglect of a minor or abuse or neglect of a vulnerable adult has occurred, we may have to report that information to a law enforcement agency or to other government entities;
  • If the client or another person has communicated to us a threat of violence to the client or to some other potential victim, we may have to inform the potential victim and/or a law enforcement agency of the threat;
  • If, in our judgment, disclosure to a parent or guardian of any treatment given to or needed by a minor client is necessary to prevent serious harm to the health of the minor client;

GOALS, PURPOSES AND PROCEDURES OF THERAPY

In general, the goals of therapy include improving and/or maintaining your capacity for healthy thought, feelings and behavior individually, in groups and/or in relationships with others. The purposes of therapy include providing you with a safe and supportive environment in which to a) identify issues and obstacles that may be interfering with healthy thought, feelings and behavior, and b) learn and implement techniques and strategies for making improvements in those areas. However, therapy is not intended as a substitute for your own capacity for thought, feelings or behavior.

The procedures utilized at Synergy eTherapy include prepaid scheduled sessions with a therapist via electronic media (e.g., video conferencing or telephone call) during which you and your therapist will communicate about your mental health status and progress toward the goals established for therapy. Because of legal and ethical requirements, your therapist cannot engage in activities or relationships with you that are not reasonably and necessarily related to therapy.

The specific therapeutic techniques that will be utilized include, but are not necessarily limited to: CBT, Psychodynamic, Mindfulness, Skill Building, Motivational Interviewing, Client-Centered, Family Systems, and Eclectic. Please discuss the specific techniques your Synergy eTherapist might use in your initial intake session. It may be necessary or desirable to change the procedures from time to time during the course of therapy. You will be informed if any changes are recommended and will be given an opportunity to decide whether to continue receiving therapy if the provider considers those changes necessary.

RISKS/BENEFITS ASSOCIATED WITH THERAPY

There are a number of potential risks associated with therapy. For example, in some cases, despite the best efforts of clients and their providers, clients make little or no progress toward their goals. It is possible, though unlikely, that the therapy could adversely affect your health temporarily or permanently. For example, the therapy could lead to recollection, awareness or discovery of events, experiences, conditions or situations that are painful, stressful or unsettling in a variety of ways. The therapy could be financially challenging for you, particularly if the cost of the therapy is not covered by an insurer or some other third party.

However, there are also a number of potential benefits associated with the therapy. For example, you could experience significant improvement in your capacity for healthy thought, feelings and behaviors. You could become aware of other issues or conditions that you want to address as part of the therapy besides those issues or conditions that were initially addressed. Overall, you could experience significant changes and progress in your quality of life as a benefit of the therapy

RISKS ASSOCIATED WITH ETHERAPY

The eTherapy that you will participate in is, in some respects, innovative in nature. In other words, eTherapy has not been used within the professional community for as long or as extensively as other in person methods of providing therapy.

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. Synergy eTherapy and each independent eTherapist are committed to working with you, the client, to maintain the confidentiality of your PHI. 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.
  • 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.

FACTORS AFFECTING DURATION AND RESULTS OF THERAPY

Many factors can impact the duration and results of therapy. They include, for example, your overall health, as well as your mental and emotional health, your motivation to do the work involved in therapy, and external factors related to finances, employment, family, and other circumstances.

ALTERNATIVES TO THE THERAPY

Although the eTherapy that is being offered is considered to be safe and effective, it is possible that alternative services or measures could be at least as safe and effective for you. Other mental health providers, physicians, and non-traditional health specialists, for example, could be beneficial, as could clergy, self-help programs and support groups. If you elect to utilize alternative services or measures in lieu of or in addition to therapy being offered by Synergy eTherapy, your therapist will coordinate care with those other services or measures as much as reasonably possible.

CLIENTS’ RIGHTS

As a client, you have certain rights according to state and federal law regarding the services you receive from Synergy eTherapy. Some of those rights appear in your state’s Bill of Rights. The state in which your Synergy eTherapist is licensed will be able to offer you that state’s Bill of Rights.

For example, you have the:

  • 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 PHI. 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.

FEES AND BILLING

The fee schedule for eTherapy is as follows: Payment before an eTherapy session by credit card. You may purchase one eTherapy session at a time unless discussed with your eTherapist.

The billing procedure for eTherapy is as follows: Payment before an eTherapy session by credit card. You will have access to your Dashboard in your Account on the Synergy eTherapy website that you can keep for your records along with invoices that are sent directly to your email on file.

Responsibility for payment for Therapy is as follows: Payment is your responsibility. We are a private pay company. You can use an HSA credit card and/or request a Superbill (if appropriate) to submit to your insurance company for partial reimbursement for out-of-network care. There is no guarantee that you will receive any reimbursement from your employer or insurance company and the payment for services is 100% the client’s (or if minor, the minor or parent/guardian’s) responsibility.

CANCELLATION POLICY

Synergy eTherapy offers therapy on an “as needed” basis, which allows you to choose, in consultation with your therapist, how often you want to receive eTherapy. Your appointment times are reserved exclusively for you, so if your scheduled time for eTherapy does not work for you, please contact your therapist directly at least 24 hours before the session start time to reschedule a service already purchased. Otherwise, you may incur a cancellation charge.

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, and it is up to your eTherapist if they have the time to go over your scheduled session time. If you show up after the halfway point of your scheduled session and did not notify your therapist that you will be late, your therapist has the right to reschedule that session and bill it as a “no show.” 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, and you do not contact your therapist within the 24 hour prior cancellation period to let them know you will be late or need to reschedule, the session may also be considered a “no show.” Once a service is purchased and the session becomes a “no show,” you will not receive a refund for that session. If several “no shows” occur, you and your therapist can discuss options for therapy that may work better for you.

QUESTIONS AND COMPLAINTS

If you have a question, comment or complaint about the services you receive from Synergy eTherapy, and you want to communicate with us about that, you may contact Dr. Lisa Herman, Psy.D., Licensed Psychologist and owner of Synergy eTherapy, via telephone at (612) 642-1355 or via email at [email protected] Also, you have legal rights under state and federal law regarding the services that you receive from Synergy eTherapy. We cannot give you legal advice regarding those rights, so you should consult with an attorney if you have questions about them. In any event, Synergy eTherapy will not retaliate against you for exercising those rights.

ACKNOWLEDGEMENT AND SIGNATURE

I acknowledge that I have read this form and that I understand it, and that I am agreeing to receive services from Synergy eTherapy according to the policies and procedures described in this form. I understand the risks and benefits of eTherapy, the nature and limits of confidentiality, my privacy, client rights, and what is expected of me as a client of Synergy eTherapy services.