SERVICE AGREEMENT Between CLIENT and

JACQUELINE NEYSA BUCKLE, M.S., LMHC

DBA BEHAVIOR COACH, PLLC

INFORMED CONSENT.   Participation in Therapy and/or Mind-Body Interventions can result in a number of benefits to you, including improved functioning, improved relationships, and resolution of the presenting problem(s).  This process requires your active participation and involvement in a consistent manner—keeping all scheduled appointments, being open and honest, asking questions and following through with assignments.

During assessment, treatment planning, or treatment, remembering or talking about certain events, feelings or thoughts may result in feelings of discomfort.  It’s important to examine events to determine whether there is a more adaptive way to respond.

Treatment modalities I typically employ are Cognitive-Behavior Therapy, Dialectical Behavior Therapy, Applied Behavior Analysis, Relaxation Training, Clinical Hypnosis, Neuro-Gen High Performance Neurofeedback (HPN), Audio/Visual Entrainment and HRV Biofeedback.  My website has further explanations of these modalities, which are safe and effective tools for eliciting mental, emotional, and physical change.

If you feel too under-activated or over-activated to drive or resume normal daily activities after any of the aforementioned treatments, you agree to wait until you are able to safely resume activities or operate your vehicle.

There is a possibility of experiencing repressed or traumatic memories when participating in certain treatment applications.  The same risks are also true of counseling in general.   If you have unanswered questions about any of the procedures used in the course of counseling, their possible risks or my expertise in employing them, please ask for an explanation.  Such questions are often very useful in the educational component of counseling.  You also have the right to ask about other treatments for your presenting problem(s) and their risks and benefits.  If you believe you could benefit from any treatment I do not provide, I can assist you in obtaining those treatments.

TREATMENT PLANNING.  During the first few sessions we will collaborate on a treatment plan, which involves your understanding of the problem(s) and the agreed-upon treatment goals to resolve them.  As the treatment process unfolds we will review and amend the goals as needed.  Your participation in symptom tracking is an important part of this process.

DUAL RELATIONSHIP.  I will never acknowledge providing treatment for anyone without his/her written permission.  In some instances, even with permission, the therapeutic relationship takes precedence and prevents my participation in any social networking invitations or other interaction.

TERMINATION.  When treatment goals have been met or there is no further benefit to continued treatment, planned termination is the best option.  Or, if treatment goals have not been met and there is another reason for discontinuing services, please feel free to discuss the reason so that continuity of care is not compromised.  If a referral to another provider is needed, I will make whatever recommendations seem appropriate to your situation.

PRIVACY & CONFIDENTIALITY.  All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.  Likewise, you are expected to keep our communications confidential and you understand that all records of communication between Client and Clinician remain the property of Jacqueline Neysa Buckle DBA Behavior Coach.  Most of the provisions explaining when the law requires disclosure are described in the Health Insurance Portability and Accountability Act (HIPAA) below.  Submission of your Intake Information confirms your acknowledgement of HIPAA.  Some of the circumstances in which disclosure is required by the law include 1) when there is a reasonable suspicion of child, dependent or elder abuse or neglect; 2) when a client presents a danger to self, to others, to property or is gravely disabled.  Disclosure may be required pursuant to a legal proceeding.  If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me.  In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.  I will use my clinical judgment when revealing such information.  I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment or unless compelled to do so by law or a valid court order.

Harm to Self or Others:  If there is an emergency during our work together or in the future after termination I become concerned about your personal safety, the possibility of you injuring someone else or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care.  For this purpose, I may also contact law enforcement, hospital or an emergency contact whose name you have provided.

Confidentiality of Distance Communication:  Treatment-related email and chat exchanges are delivered via secure encrypted transmission.  You agree to also use encrypted email.  Online platforms from which I practice provide approved methods of encrypted interaction.  If you choose to email me from your personal email account–unless it is secure–please limit the contents to housekeeping issues such as cancellation or change in contact information.  I make every effort to keep all information confidential.  Likewise, if we are working Online together, I ask that you determine who has access to your computer and electronic information from your location.  I encourage you to only communicate through a computer that you know is safe and confidentiality can be ensured.  Be sure to fully exit all online counseling sessions and emails.  If we are unable to connect or are disconnected during a session due to a technological problem, please try to reconnect within 10 minutes.  If reconnection is not possible, email or text my phone to schedule a new session time.

Litigation Limitation:  Due to the nature of the treatment process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the counseling records be requested.  Consultation: I consult as needed with other professionals regarding my clients; however, the client’s name or other identifying information is never disclosed.  The client’s identity remains completely anonymous and confidentiality is fully maintained.

EMERGENCY PROCEDURES.  If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 800-784-2433 or dial 911.  If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911 or immediately go to a hospital emergency room.

DISPUTES.  All disputes arising out of or in relation to this agreement to provide counseling services shall first be referred to mediation with a neutral third party.  In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed.  Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no payment agreement, I can use legal means (court, collection agency, etc.) to obtain payment.  The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees.  In the case of arbitration, the arbitrator will determine that sum.

CANCELLATION.  Since scheduling an appointment involves the reservation of time (and office space for local clients), a minimum of 24-hours notice is required for rescheduling or canceling an appointment whether in Office or Online.  Nonattendance of a prepaid session forfeits payment unless there is a compelling reason for missing the session.  Late arrival–after 20 minutes–is considered as a cancellation.

PAYMENTS.  Session payments are required at least 48 hours before each scheduled appointment, payable online unless other arrangements have been made.

INSURANCE.  For Online clients, determine whether your healthcare insurance will cover distance counseling.  You understand that distance/online counseling with me is not a substitute for medical care.  You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts.  As stated previously, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room.  You also understand that I follow the laws and professional regulations of the State of Florida (USA) and the counseling will be considered to take place in the state of Florida (USA).  For Office clients who use insurance—you understand you are financially responsible for my fee regardless of insurance.

SERVICE AGREEMENT.  Scheduling appointments indicates you 1) Have reviewed the information available on my website.  2) Have submitted the required Intake Information.  3) Have read, understand and agree to the terms of this Service Agreement/Informed Consent form,  and  4) Have read, understand and agree to the HIPAA Notice.

“Health Insurance Portability and Accountability Act (HIPAA)”

Your Information.  Your Rights.  Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a specific address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

Our Uses and Disclosures

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services. 

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information:  www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on our web site.