forms & practice information
Useful information and required forms.
A list is below so you can easily find your way to the one(s) you need for now.
Forms are shown here for your information and ongoing reference. Copies are available through secure communication. Just ask.
list of contents
Step by Step
Details about beginning the connection process.
Telehealth - General Tips - TherapyNotes and Tele-health
Details about working with TherapyNotes service.
HIPAA Privacy Notice
For all clients - new and existing
A complete and compact explanation of your rights and limits.
You will be asked to sign a copy.
Communications Policy - Current
Provides understanding to better inform your ability to give consent. Explains how we will and will not communicate. You will be asked to sign a copy.
Email & Text Risk Questionnaire - Current
Information so you can review and consider your privacy and communication methods.
You will be asked to indicate your choices and sign a copy.
content list continued
Tele-health Consent - Earlier
For clients prior to October 2021 - Provides understanding to better inform your ability to give consent. You will be asked to sign a copy.
Communications Policy - Earlier
For clients prior to October 2021 -Explains how we will and will not communicate.
You will be asked to sign a copy.
Communication Risk Assessment - Earlier
For clients prior to October 2021 -Information so you can review and consider your privacy and communication methods.
You will be asked to indicate your choices and sign a copy.
You will be signing & receiving a lot of copies
It is good to remember that even if you lose track of your copies, the information is located on this website. Or you can just ask for another copy.
step by step
How We Get Started
We have talked. We have decided to establish at least a first appointment. Now there are the official things to do. Always happy to explain and it helps to have such things in writing for easier reference.
You cannot download the forms from here.
I will send them to you within the secure portal.
First - you give me a private-yours-only email address. And date of birth.
Second - I set you up as a client so that TherapyNotes can send you an invitation with a link to join.
Third - you accept the invitation and follow their directions. I will be notified. Helpful to add appointmentreminders@therapyportal(dot)com to your address book. Also add 512.768.2553 to your phone as the number for text appointment reminders. You CANNOT text me at this number.
Fourth - I send you all the forms shown on this page plus a few others: Intake Questionnaire & Consent for Treatment; Medication & Supplement Information; Insurance Information (if using insurance); and Credit Card Information - Authorization to Secure Payment. Most forms require reading and a signature. Others require you to provide useful information. All forms are required.
Fifth - you complete and return all forms through the portal.
Sixth - we set or confirm our first appointment. This initial session will be for 80 minutes. I will create the appointment and the invitation will be sent.You will receive both a text reminder and an email reminder.
Seventh - I send the ongoing assessment forms that we will use to track your progress and experience. Just print these out to have available. There is no need to try and complete them ahead of time. We will be doing assessments as we go along.
telehealth - general tips
Getting Started with TherapyNotes
I am now using TherapyNotes, a secure video service for online sessions. I chose TherapyNotes because it’s user friendly and has robust features and support. That said, there are some very important things you’ll need to know in order to avoid the potential frustration of not being able to connect at our scheduled appointment time.
If I have added you as a client - the system automatically generates an email that contains a link that you MUST click on to accept the invitation and join TherapyNotes. When you click the link, you’ll create your password and type in some other information. That first email might go to your junk/spam/clutter file, so go ahead and look for that at your earliest convenience.
Consider updating your contact information so that notices do not go to your spam folder.
therapyportal.com for invitations and notices
512-768-2553 for text reminders and notices
As soon as you have your log in information, you can log into TherapyNotes. The dashboard will list your appointment details after I schedule it with a green join button that is available 2 hours prior to your appointment. The portal also has a menu on the left called support, which can further answer any questions.
If you’re using a PC, Mac, or Android device, please use Chrome, Firefox, or Safari version 12.2 or greater. If you are using an iPhone or iPad, use Safari 12.2 or higher.
Rebooting your computer before a session is a good idea especially if you’ve used other applications during the day that utilize your speakers/camera/microphone - not required but it’s often helpful with some systems.
Finally, keep in mind that when using TherapyNotes, the more bandwidth you have available, the better your connection will be. Therefore, if you’re planning on using a phone or tablet, connecting to Wi-Fi will vastly improve the session.
Disconnections may occur. If we get disconnected, I’ll restart the session on my side. If you don’t see me in a few minutes, go back to the Dashboard and click the green join button again. I will call you if more than a few minutes have elapsed.
We can learn to do this.
Appointments (regardless of type or location) are scheduled by phone calls/phone messages. Cancelations cannot be done in the TherapyNotes system. Cancelations still follow our cancelation policy agreement.
I’m looking forward to meeting with you using this technology. If you have any questions, feel free to call me.
214.824.2009
HIPAA - privacy notice
Health Insurance Portability and Accountability Act
This notice continues to be a separate form.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
In this Privacy Notice, “medical information” and “psychological information”
mean the same as “health information.” Health information includes any
information that relates to: 1) your past, present, or future physical or
mental health or condition; 2) providing health care
to you; or 3) the past, present, or future payment for your health care.
Protecting Your Privacy:
Counselors must always manage psychological records with great concern for
privacy and confidentiality. I am required by law to protect the privacy of
your health information. This means that I will not use or disclose your
health information without your authorization except
in the ways I tell you in this notice. If I wish to use or disclose your
health information in ways other than those stated in this notice, I will ask
you for your written authorization. If you give such an authorization, you
may revoke it at any time, but I will not be liable for uses or disclosures
made before you revoked your authorization.
Although the security of psychological records has continuously been
addressed by Counseling Codes of Ethics as well as by State and Federal laws,
the rules have been considerably strengthened by the provisions of the Health
Insurance Portability and Accountability Act (HIPAA). The following
information provides details about the provisions of HIPAA and your rights
concerning privacy and your psychological records.
Who will observe these rules?
In my practice, the following individuals are required by HIPAA to comply
with the privacy rules:
• Me and any practice staff such as office manager/scheduler, etc..
• Any billing agency or collection agency that handles information about you
(name and address, diagnostic codes, treatment codes, and consultation
dates...but not actual clinical records)
YOUR RIGHTS REGARDING PSYCHOLOGICAL INFORMATION ABOUT YOU:
1) The Right to Inspect and Obtain a Copy of Your Psychological Record
Professional records constitute an important part of the therapy process and
help with the continuity of care over time. According to the rules of HIPAA,
your consultations are documented in two ways: 1) The Clinical Record
(required), which includes the date of your consultations, your reasons for
seeking therapy, your diagnosis, therapeutic goals, treatment plan, progress,
medical and social history, treatment history, functional status, any past
records from other providers, and any reports to your insurance carrier; and
2) Psychotherapy Notes (optional), which consist of specific content or
analyses of therapy conversations (some of which may include sensitive
information you have revealed that is not required to be included in your
Clinical Record) and therapist’s notes that may assist in treatment.
Psychotherapy Notes, if created, are never disclosed to third parties, HMOs,
insurance companies, billing agencies, patients, or anyone else. If your case
manager or insurance company requests to see the psychotherapy notes, you
have a choice about consenting (signing a Release of Information form) or
denying access to them. If you refuse, it will not affect your coverage or
reimbursement in any way, and your insurance company or HMO is obliged to
provide payment, as usual.
2. The Right to Request a Correction or Add an Addendum to Your Psychological
Record Correction 3. The Right to an Accounting of Disclosures of Your
Psychological Information to Third Parties 4. The Right to Request
Restrictions on How Your Information is Used
5. The Right to Request Confidential Communications
6. The Right to a Copy of This Notice upon Request
7. The Right to Withdraw Permission to Disclose Health Information
8. The Right to File a Complaint You have the right to file a complaint if
you believe your privacy rights have been violated. Complaints must be filed
in writing, and may be addressed directly to your therapist, or to the
Secretary of the Department of Health and Human Services (address: Office for
Civil Rights, 200 Independence Ave., S.W. Washington, DC 20201). If you have
any questions or concerns about this notice or your health information
privacy, please do not hesitate to address them during session or contact my
office by telephone.
9. The Right to be Notified in There is a Breach of Your Unsecured PHI You
have a right to be notified if: (a) there is a breach (a use or disclosure of
your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that
PHI has not been encrypted to government standards; and (c) our risk
assessment fails to determine that there is a low probability that your PHI
has been compromised.
10. The Right to Restrict Disclosures When You Have Paid for Your Care Out-
of-Pocket -
You have the right to restrict certain disclosures of PHI to a health plan
when you pay out-of- pocket in full for services.
I understand that this Privacy Notice is available at any time on DeborahBeckman.com print name & sign below & date
______________________________________________________________________
My signature above represents that I have read and understand my rights under
HIPAA.
Worth knowing
Your privacy matters. Much has been done to establish the careful protection outlined in HIPAA
To adore - cherish, honor, revere, venerate, or to have a great affection for
To endure - to bear patiently, to last or continue to exist
partial definitions from the Free Dictionary by Farlex
communication policy
effective September 2023
Please complete all requested information & remember to provide any changes.
Information & Policies for Informed Consent for Treatment
Deborah Beckman, MS, LPC, NCC is a private practice that provides therapeutic services. The therapeutic relationship can be described by the scope and limits of confidentiality.
Confidentiality is the act of holding anything said or done within the therapy session as private. Therapy is an intense personal relationship that relies on a therapist maintaining professional standards and limits. There is no social relationship possible. You are free to discuss your therapeutic
experience with individuals in your personal life. You are free to ignore or acknowledge me should you encounter me outside of session and in a public space.
The conditions that limit confidentiality are: (1)it is determined that you are a danger to yourself; (2)it is
determined that you are a danger to someone else; (3)you have information regarding abuse or are abusing a child or other dependent person; (4)you have provided written permission for disclosure of information; (5)court ordered release of information; (6)information pertinent for clinical supervision
or consultation (all clinicians are bound by the same scope and limits of confidentiality). If clinically advisable, you will be informed of action taken with regard to the limits of confidentiality.
I will be working with you to clarify and establish goals; however, no one can offer a guarantee that your goals will be accomplished. For some clients, only a few sessions may be required while other clients may require years of consistent therapy. You have the choice to end your therapy at any time. It
would be beneficial to have a final session to summarize and terminate the relationship. Every effort will be taken to be on time and ready for your session to begin and the same effort is asked of you.
How to Contact Me
When you need to contact me, Deborah Beckman, for any reason, these are the most effective ways to get in touch in a reasonable amount of time:
- By phone at 214.824.2009. You may leave messages on the voicemail, which is confidential. This is the best and most consistent means of contact.
- By secure portal messaging(coming soon in TherapyNotes)
- If you wish to communicate with me by normal email or normal text message, please read and complete the Email & Text Risk Questionnaire form which is available. At that time, the phone number and/or email will be provided.
I subscribe to a service that can allow us to communicate more privately through the use of encryption and other privacy technologies. None of them will cost you money, but it requires some setup before it can be used. TherapyNotes for a secure client portal.
TherapyNotes will be implementing a secure messaging system soon. In the meantime, we will be using a combination of voicemail and text.
If you need to send a file such as a PDF or other digital document:
- send using the TherapyNotes secure client portal service.
- FAX it to 214.824.2081 secured fax line via
Please refrain from making contact with me using social media messaging systems such as Facebook Messenger Twitter or others. These methods have very poor security and I am not prepared to watch them closely for important messages from clients.
It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.
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. (weekends/holidays are excepted from this timeframe.) I may be able to reply more quickly than that, but please be aware that this will not always be possible.
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. When possible, you will be informed. My voice mail message has current information.
Emergency Contact
If you are ever experiencing an emergency, including a mental health crisis, please call
Suicide and Crisis Center of North Texas at 214.828.1000
or 911
or 988 Suicide & Crisis Lifeline
Additional crisis services are listed on my website, DeborahBeckman.com on the Depression page. Become familiar with them prior to any need.
If you need to contact me about an emergency, the best method is by phone 214.824.2009
Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole method of communicating with me in emergencies.
Disclosure Regarding Third-Party Access to Communications
Please know that if we use electronic communications methods, such as email, texting, online video, and possibly others, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.
Of special consideration are work email addresses. If you use your work email or phone to communicate with me, your employer may access our communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with.
Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other.
I have read and understand the above. I understand that this Communications Policy is available at any time on DeborahBeckman.com
Signed by __________________________________ Date ______________
Content adapted from PersonCenteredTech.com material 2020
Email & Text Risk Questionnaire
effective September 2023 & please remember to provide any changes
Regarding Email
- Technical experts often describe email as being like a postcard, in that it can be viewed by all hands it passes through. Are you familiar with the risks of emails being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
- Think about where you read and write emails, and what devices you do that on. Think about who can see you reading and writing emails in these places, and who can access the devices you use to read and write emails. Would there be any negative consequences to any of those people reading or glancing at emails exchanged with your therapist? Are there certain kinds of email contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use email with him or her.
- Think about which email address(es) you might use with your therapist. Who has access to each address? If you use a work email address, know that your employer may legally view all the emails your send receive with that address. Be aware that engineers and administrators at your email service provider may be able to view your emails.
- How quickly do you normally receive replies from others via email? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to an email as quickly as others in your life typically do?
Your therapist’s email service are through these companies: TherapyNotes for secure “client portal” communication. Professional business email is through regular channel Gmail.
Regarding Texting
- Text messages are often sent using the Internet, even though they are usually a part of one’s phone service. Are you familiar with the risks of texts being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
- Are you aware that text messages wait on phone company computers until they are retrieved, and may remain there indefinitely? Can you imagine any negative consequences if engineers, administrators, or law enforcement personnel viewed these stored texts from or to your therapist?
- Think about where you read and write text messages, and what devices you do that on. Think about who can see you reading and writing texts in these places, and who can access the devices you use to read and write texts. Would there be any negative consequences to any of those people reading or glancing at texts exchanged with your therapist? Are there certain kinds of text contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use texting with him or her.
- How quickly do you normally receive replies from others via text? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to a text as quickly as others in your life typically do?
Your therapist uses the following device(s) and phone service(s) to send and receive text messages: iPhone 11 with T-Mobile
Note that there are some interesting effects depending on what devices you and clients use. For example, if both client and therapist use iPhones, then your text messages may not be typical SMS text messages. Instead, your messages may be iMessage chat messages. On iPhones, iMessage chats are colored blue, while classic SMS text messages are colored green.
I choose to communicate with you by (initial all that apply):
_____ Deborah's office phone & voice mail - required primary contact information
_____ client phone & voice mail - required primary contact information
_________________ preferred client phone for contact
_____ TherapyNotes client portal email for practical matters
______________________________ preferred client email for contact through TherapyNotes
_____ text to cell phone for practical matters and appointment reminders
I have read and understand the above. I understand this information is available at DeborahBeckman.com
Signed by __________________________________ Date ______________
Relationship to Client _____________________ Phone _____________
Content adapted from PersonCenteredTech.com material 2020
using this document
This questionnaire is written for you, the client, to read on your own. However, remember that the purpose of it is to supply a jumping off point for your therapist to meet the threshold set by the 2014 ACA Code of Ethics for informing clients of risks involved in the use of digital and networked communications technology. So we can use this questionnaire to help us structure a discussion about the risks involved. The final purpose of such a discussion would be to:Help clients determine if the risks involved in email and/or texting are acceptable to them and/orHelp clients and their therapist find what needs to be done to reduce the risks to reasonable levels. E.g. the client may limit what kinds of communications are acceptable, may choose to use a different email address, etc.
communications policy
October 2021 - September 2023
The following is a revised version of earlier forms identified below. The original forms are still showing as they are actively in use by many clients and will remain available for review.
At the end of each page you will be asked to print your name, date, and initial this statement -
I have read and understand the above. I understand that this information is available at any time on DeborahBeckman.com
Information & Policies for Informed Consent for Treatment
Deborah Beckman, MS, LPC, NCC is a private practice that provides therapeutic services. The therapeutic relationship can be described by the scope and limits of confidentiality. Confidentiality is the act of holding anything said or done within the therapy session as private. Therapy is an intense personal relationship that relies on a therapist maintaining professional standards and limits. There is no social relationship possible. You are free to discuss your therapeutic experience with individuals in your personal life. You are free to ignore or acknowledge me should you encounter me outside of session and in a public space.
The conditions that limit confidentiality are: (1)it is determined that you are a danger to yourself; (2)it is determined that you are a danger to someone else; (3)you have information regarding abuse or are abusing a child or other dependent person; (4)you have provided written permission for disclosure of information; (5)court ordered release of information; (6)information pertinent for clinical supervision or consultation (all clinicians are bound by the same scope and limits of confidentiality). If clinically advisable, you will be informed of action taken with regard to the limits of confidentiality.
I will be working with you to clarify and establish goals; however, no one can offer a guarantee that your goals will be accomplished. For some clients, only a few sessions may be required while other client may require years of consistent therapy. You have the choice to end your therapy at any time. It would be beneficial to have a final session to summarize and terminate the relationship. Every effort will be taken to be on time and ready for your session to begin and the same commitment is asked of you.
Communications Policy
How to Contact Me
The most effective ways to get in touch in a reasonable amount of time are:
- By phone at 214.824.2009. You may leave messages on voicemail, which is confidential. This is the best and most consistent means of contact.
- By secure messaging through thera-LINK
- If you wish to communicate with me by regular email or regular text message, please read and complete the Consent For Non-Secure Communications section of this form.
thera-LINK is a “client portal” service that allows us to communicate securely through the use of encryption and other privacy technologies. There is no fee. It requires some setup before it can be used. This is not an “instant” form of communication.
If you need to send a file such as a PDF or other digital document:
- send using the thera-LINK secure client portal document service.
- print and FAX it to 214.824.2081.
It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.
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. (weekends/holidays are excepted from this timeframe.) I may be able to reply more quickly than that, but please be aware that this will not always be possible.
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. When possible, you will be informed. My voice mail message has current information.
Emergency Contact
If you are ever experiencing an emergency, including a mental health crisis, please call
Suicide and Crisis Center of North Texas at 214.828.1000.
Additional crisis services are listed on my website, DeborahBeckman.com on the Depression page. Become familiar with them prior to any need.
If you need to contact me about an emergency, the best method is by phone 214.824.2009
Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole method of communicating with me. This is especially true for an emergency.
Disclosure Regarding Third-Party Access to Communications
Please know that if we use electronic communications methods, such as email, texting, online video, and possibly others, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.
Of special consideration are work email addresses. If you use your work email or phone to communicate with me, your employer may access our communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with. Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other.
Email and Text Risk Questionnaire
This questionnaire is for you to read on your own. I am ethically bound to meet the threshold set by the 2014 ACA Code of Ethics for informing clients of risks involved in the use of digital and networked communications technology. This questionnaire is to help you think about the risks involved and structure a discussion with me to determine what is acceptable.
The final purpose of such a discussion would be to:
Help determine if the risks involved in email and/or texting are acceptable and/or
Help find what needs to be done to reduce the risks to reasonable levels. E.g. you may limit what kinds of communications are acceptable, may choose to use a different email address, etc.
Regarding Email
- Technical experts often describe email as being like a postcard, in that it can be viewed by all hands it passes through. Are you familiar with the risks of emails being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
- Think about where you read and write emails, and what devices you do that on. Think about who can see you reading and writing emails in these places, and who can access the devices you use to read and write emails. Would there be any negative consequences to any of those people reading or glancing at emails exchanged with your therapist? Are there certain kinds of email contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use email with him or her.
- Think about which email address(es) you might use with your therapist. Who has access to each address? If you use a work email address, know that your employer may legally view all the emails your send receive with that address. Be aware that engineers and administrators at your email service provider may be able to view your emails.
- How quickly do you normally receive replies from others via email? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to an email as quickly as others in your life typically do?
Your therapist’s email service are through these companies: thera-LINK for secure “client portal” communication. Professional business email is through regular channel Gmail.
Regarding Texting
- Text messages are often sent using the Internet, even though they are usually a part of one’s phone service. Are you familiar with the risks of texts being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
- Are you aware that text messages wait on phone company computers until they are retrieved, and may remain there indefinitely? Can you imagine any negative consequences if engineers, administrators, or law enforcement personnel viewed these stored texts from or to your therapist?
- Think about where you read and write text messages, and what devices you do that on. Think about who can see you reading and writing texts in these places, and who can access the devices you use to read and write texts. Would there be any negative consequences to any of those people reading or glancing at texts exchanged with your therapist? Are there certain kinds of text contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use texting with him or her.
- How quickly do you normally receive replies from others via text? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to a text as quickly as others in your life typically do?
Your therapist uses the following device(s) and phone service(s) to send and receive text messages: iPhone SE with T-Mobile
Note that there are some interesting effects depending on what devices you and clients use. For example, if your client and you both use iPhones, then your text messages may not be typical SMS text messages. Instead, your messages may be iMessage chat messages. On iPhones, iMessage chats are colored blue, while classic SMS text messages are colored green.
I choose to communicate with you by (initial all that apply):
_____ office phone & voice mail - required primary contact information
_____ client phone & voice mail - required primary contact information
_________________ preferred client phone for contact
_____ thera-LINK client portal email for practical matters
_______________________ preferred client email for contact through thera-LINK
_____ text to cell phone for practical matters
I prefer to receive mail at ______________________________________________
I prefer to receive email at ______________________________________________
Content adapted from PersonCenteredTech.com material 2020
Informed Consent Addendum for Online Therapy
This is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure all of your questions are answered before signing to give consent.
This is to be used in conjunction with, but does not replace, the Intake Questionnaire and Consent for Treatment document that is required of all clients prior to starting therapy services.
Online therapy or tele-therapy is defined as the use of technology to have a therapy session. We will use thera-LINK, a HIPAA compliant platform that uses video and audio technology through a webcam on your device and my device.
thera-LINK uses encrypted data streams (AES-256) for our video sessions. Any data that is stored outside of our video session on the thera-LINK platform (such as documents, messages, or progress notes) is encrypted and meets or exceeds all HIPAA and HITECH guidelines.
The benefits of tele-therapy include the convenience of location, time, wait times, and accessibility which allows for better continuity of care. In addition, tele-therapy allows for greater accessibility to services for clients with limited mobility or with lack of transportation. Tele-therapy can also allow for couples or families to meet when in different locations.
With all technology, there are also some limitations. Technology may occasionally fail before or during our session. The problems may be related to internet connectivity, difficulties with hardware, software, equipment, and/or services supplied by a 3rd party. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video, the therapist will either use the in-session video chat to trouble shoot or will call you back to complete the session. Please list your main number and an alternate number here: _______________________________________.
If, for any reason, we are unable to connect and you are in an immediate crisis or a potentially life-threatening situation, get immediate emergency assistance by calling 911.
I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION.
I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services.
I understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.
I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.
I understand that I am not allowed to do any recording, screenshots, etc. of any kind, of any session, and are grounds for termination of the client-therapist relationship.
Consent to Treatment
I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Deborah Beckman, MS, LPC, NCC to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Deborah Beckman, MS, LPC, NCC at any time. I understand Deborah Beckman, MS, LPC, NCC will determine on an on-going basis whether the condition being assessed and/or treated is appropriate for online therapy.
By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
I am responsible for maintaining the ethical guidelines of practice as established by the Texas State Board of Examiners of Professional Counselors. You are encouraged to address any complaints or dissatisfaction directly with me. However, should your complaint not be resolved, please notify the Texas State Board of Examiners of Professional Counselors at 800.942.5540.
Appointments are typically 55 - 60 minutes in length. Your fee for sessions, based on a sliding scale published on my website, will be ______ and due at the time of service unless other arrangements are made.
Fees will be due for appointments missed without a minimum of 28 hours notice.
I, the undersigned, understand and agree to all of the above. I understand that this
Information & Policies for Informed Consent for Treatment
is available at any time on DeborahBeckman.com
information for new clients
General Consent
FOR USE BY CLIENTS PRIOR TO OCTOBER 2021
Uptown Psychotherapy Associates or Uptown Psychotherapy (UPA) is a private practice that provides therapeutic services. This includes individual and couples sessions.
The therapeutic relationship is best described by the scope and limits of confidentiality. Confidentiality is the act of holding anything said or done within the therapy session as private. Therapy is an intense personal relationship that relies on the therapist maintaining professional standards and limits. There is no social relationship possible with your therapist. You are free to discuss your therapeutic experience with individuals in your personal life. You are free to ignore or acknowledge your therapist should you encounter your therapist outside the office.
The conditions that limit confidentiality are: (1)it is determined that you are a danger to yourself; (2)it is determined that you are a danger to someone else; (3)you have information regarding abuse or are abusing a child or other dependent person; (4)you have provided written permission for disclosure of information; (5)court ordered release of information; (6)information pertinent for clinical supervision or consultation (all clinicians are bound by the same scope and limits of confidentiality). If clinically advisable, you will be informed of action taken with regard to the limits of confidentiality.
Further, confidentiality cannot be guaranteed should you communicate with your therapist via email or text or other electronic/social media means. There is a separate explanation and release for secure HIPAA compliant tele-health should that format be used for therapeutic services.
Your therapist will be working with you to clarify and establish goals; however, no one can offer a guarantee that your goals will be accomplished. For some clients, only a few sessions may be required while other client may require years of consistent therapy. You have the choice to end your therapy at any time. It would be beneficial to have a final session with your therapist to summarize and terminate the relationship. Every effort will be taken by your therapist to be on time and ready for your session to begin and the same commitment is asked of you.
Your therapist is responsible for maintaining the ethical guidelines of practice as established by the Texas State Board of Examiners of Professional Counselors. You are encouraged to address any complaints or dissatisfaction directly with your therapist. However, should your complaint not be resolved, please notify the Texas State Board of Examiners of Professional Counselors at 800.942.5540.
Appointments are typically 55 - 60 minutes in length. Your fee for sessions, based on a sliding scale, will be _____ and due at the time of service unless other arrangements are made.
Fees will be due for appointments missed without a minimum of 28 hours notice.
I, the undersigned, understand and agree to all of the above. I have been given a copy.
Signed By Date
Relationship to client
Witnessed By Date
_____ Check here if you do not want to be on the mailing list.
I prefer to receive mail at (email)
Confidentiality
Privacy is an important, enduring part of any health care. There are many ways it is protected. And ways in which it is limited. For more than your therapy with me - learn what confidentiality consists of as described by HIPAA. Learn what you can protect. Then learn what the limits are when using insurance, consultation, etc.
Telehealth Consent
FOR USE BY CLIENTS PRIOR TO OCTOBER 2021
INFORMED CONSENT ADDENDUM FOR ONLINE THERAPY
YOU WILL BE GIVEN A COPY OF THIS FORM TO SIGN
This form is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure all of your questions are answered before signing to give consent.
This is to be used in conjunction with, but does not replace, the Informed Consent document that is required of all clients prior to starting therapy services.
Online therapy or tele-therapy is defined as the use of technology to have a therapy session. We will use thera-LINK, a HIPAA compliant platform that uses video and audio technology through a webcam on your device and my device to connect us securely.
thera-LINK uses encrypted data streams (AES-256) for our video sessions. Any data that is stored outside of our video session on the thera-LINK platform (such as documents, messages, or progress notes) is encrypted and meets or exceeds all HIPAA and HITECH guidelines.
The benefits of tele-therapy include the convenience of location, time, wait times, and accessibility which allows for better continuity of care. In addition, tele-therapy allows for greater accessibility to services for clients with limited mobility or with lack of transportation. Tele-therapy can also allow for couples or families to meet when in different locations.
With all technology, there are also some limitations. Technology may occasionally fail before or during our session. The problems may be related to internet connectivity, difficulties with hardware, software, equipment, and/or services supplied by a 3rd party. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video, the therapist will either use the in-session video chat to trouble shoot or will call you back to complete the session. Please list your main number and an alternate number here: __________________________________________________.
If, for any reason, we are unable to connect and you are in an immediate crisis or a potentially life-threatening situation, get immediate emergency assistance by calling 911.
I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.
I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.
I understand that I am not allowed to do any recording, screenshots, etc. of any kind, of any session, and are grounds for termination of the client-therapist relationship.
Consent to Treatment
I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Deborah Beckman, MS, LPC, NCC to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Deborah Beckman, MS, LPC, NCC at any time. I understand Deborah Beckman, MS, LPC, NCC will determine on an on-going basis whether the condition being assessed and/or treated is appropriate for online therapy.
By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
___________________________________
Patient/Client Signature
___________________________________
Parent, Guardian or Legal Representative Signature (if minor or needed otherwise)
___________________________________
Date
communications policy
How to Contact Me
FOR USE BY CLIENTS PRIOR TO OCTOBER 2021
When you need to contact me, Deborah Beckman, for any reason, these are the most effective ways to get in touch in a reasonable amount of time:
- By phone at 214.824.2009 You may leave messages on the voicemail, which is confidential. This is the best and most consistent means of contact.
- By secure email (see below for details.)
- If you wish to communicate with me by normal email or normal text message, which does not include any form of social media, please read and complete the Consent For Non-Secure Communications form which is available. At that time, the phone number and/or email will be provided.
I subscribe to a service that can allow us to communicate more privately through the use of encryption and other privacy technologies. None of them will cost you money, but it requires some setup before it can be used. Please ask if you would like to use this service:
- thera-LINK for a secure “client portal,” where we can exchange private messages via a secured website. This is not an “instant” form of communication.
If you need to send a file such as a PDF or other digital document:
- send using the thera-LINK secure client portal email service.
Please refrain from making contact with me using social media messaging systems such as Facebook Messenger Twitter or others. These methods have very poor security and I am not prepared to watch them closely for important messages from clients.
It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.
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. (weekends/holidays are excepted from this timeframe.) I may be able to reply more quickly than that, but please be aware that this will not always be possible.
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. When possible, you will be informed. My voice mail message has current information.
Emergency Contact
If you are ever experiencing an emergency, including a mental health crisis, please call -
Suicide and Crisis Center of North Texas at 214.828.1000.
Additional crisis services are listed on my website, DeborahBeckman.com on the Depression page. Become familiar with them prior to any need.
If you need to contact me about an emergency,
the best method is by phone 214.824.2009
Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole method of communicating with me in emergencies.
Disclosure Regarding Third-Party Access to Communications
Please know that if we use electronic communications methods, such as email, texting, online video, and possibly others, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.
Of special consideration are work email addresses. If you use your work email or phone to communicate with me, your employer may access our communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with. Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other.
I have read and understand the above. I have been given a copy.
Signed by ______________________________________Date _______________
Relationship to Client _____________________ Phone _____________________
Witnessed by __________________________________ Date _______________
Content adapted from PersonCenteredTech.com material 2020
No Social Media
To Repeat -
Please refrain from making contact with me using social media messaging systems such as Facebook Messenger Twitter or others. These methods have very poor security and I am not prepared to watch them closely for important messages from clients.
It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.
email & texting risk questionnaire
Regarding Email & Texting
FOR USE BY CLIENTS PRIOR TO OCTOBER 2021
Regarding Email
- Technical experts often describe email as being like a postcard, in that it can be viewed by all hands it passes through. Are you familiar with the risks of emails being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
- Think about where you read and write emails, and what devices you do that on. Think about who can see you reading and writing emails in these places, and who can access the devices you use to read and write emails. Would there be any negative consequences to any of those people reading or glancing at emails exchanged with your therapist? Are there certain kinds of email contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use email with him or her.
- Think about which email address(es) you might use with your therapist. Who has access to each address? If you use a work email address, know that your employer may legally view all the emails your send receive with that address. Be aware that engineers and administrators at your email service provider may be able to view your emails.
- How quickly do you normally receive replies from others via email? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to an email as quickly as others in your life typically do?
Your therapist’s email service are through these companies: thera-LINK for secure “client portal” communication. Professional business email is through regular channel Gmail.
Regarding Texting
- Text messages are often sent using the Internet, even though they are usually a part of one’s phone service. Are you familiar with the risks of texts being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
- Are you aware that text messages wait on phone company computers until they are retrieved, and may remain there indefinitely? Can you imagine any negative consequences if engineers, administrators, or law enforcement personnel viewed these stored texts from or to your therapist?
- Think about where you read and write text messages, and what devices you do that on. Think about who can see you reading and writing texts in these places, and who can access the devices you use to read and write texts. Would there be any negative consequences to any of those people reading or glancing at texts exchanged with your therapist? Are there certain kinds of text contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use texting with him or her.
- How quickly do you normally receive replies from others via text? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to a text as quickly as others in your life typically do?
Your therapist uses the following device(s) and phone service(s) to send and receive text messages: iPhone 11 with T-Mobile
Note that there are some interesting effects depending on what devices you and clients use. For example, if your client and you both use iPhones, then your text messages may not be typical SMS text messages. Instead, your messages may be iMessage chat messages. On iPhones, iMessage chats are colored blue, while classic SMS text messages are colored green.
I choose to communicate with you by (initial all that apply):
_____ office phone & voice mail - required primary contact information
_____ client phone & voice mail - required primary contact information
_________________ preferred client phone for all contact
_____ thera-LINK client portal email for practical matters
_____ text to cell phone for practical matters
I have read and understand the above. I have been given a copy.
Signed by __________________________________ Date ______________
Relationship to Client _____________________ Phone _____________
Content adapted from PersonCenteredTech.com material 2020
Using This Document
This questionnaire is written for the client to read on his/her own. However, remember that the purpose of it is to supply a jumping off point for you, the therapist, to meet the threshold set by the 2014 ACA Code of Ethics for informing clients of risks involved in the use of digital and networked communications technology. So you can use this questionnaire to help you structure a discussion with clients, you can give it to clients to help them think about the risks involved before they discuss them with you, or for whatever purposes you judge is helpful for you to meet your requirements.
The final purpose of such a discussion would be to:
Help clients determine if the risks involved in email and/or texting are acceptable to them and/or help clients and you find what needs to be done to reduce the risks to reasonable levels. E.g. the client may limit what kinds of communications are acceptable, may choose to use a different email address, etc.