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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.

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In office or thera-LINK

Forms are shown here for your information and ongoing reference. Copies are available either when we meet in the office or through secure communication via Thera-LINK.

list of contents

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thera-LINK and Tele-health

Details about working with thera-LINK service.

Information for New Clients

Information and explanation helping  grant "informed consent" and understanding  confidentiality. You will be asked to sign a copy.

Tele-health Consent

Provides understanding to better inform your ability to give consent. 

You will be asked to sign a copy. 

HIPAA Privacy Notice

A complete and compact explanation of your rights and limits. 

You will be asked to sign a copy.

content list continued

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Communications Policy

Explains how we will and will not communicate. 

You will be asked to sign a copy. 

Communication Risk Assessment

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.

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tele-health

Getting Started with thera-LINK

I am now using thera-LINK, a secure video service for online sessions. I chose thera-LINK because it’s very user friendly. 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.


I’ve added you as a client on thera-LINK. The system automatically generated an email that contains a link that you MUST click on to accept the invitation and join thera-LINK. 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. 


As soon as you have your log in information, you can log into thera-LINK. 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.  


Once you’ve logged in, you can click on the settings menu to upload a picture of yourself if you’d like. thera-LINK auto detects your time zone and your appointments will be displayed accordingly. 


Finally, keep in mind that when using thera-LINK, 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 5 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 thera-LINK 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

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information for new clients

General Consent

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.    

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Tele-Health Consent

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


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HIPAA - privacy notice

Health Insurance Portability and Accountability Act

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.


__________________________________________       Date  ________________

My signature above represents that I have read and understand my rights under HIPAA. I understand that this Privacy Notice is available at any time on DeborahBeckman.com 


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

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communications policy

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 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. 
  • print and FAX it to 214.824.2081.


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.

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email & texting risk questionnaire

Regarding Email & Texting

Regarding Email

  1. 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?
  2. 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.
  3. 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.
  4. 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

  1. 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?
  2. 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?
  3. 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.
  4. 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.

Photo Credits

Desk of Things photo - Dustin Lee   Spellcheck Typewriter photo - Suzy Hazelwood

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Thank You on Door photo - Matt Jones  

Neon Thank You photo - Ryan McGuire   Adore & Endure photo - Toa Heftiba

Silhouette Night Sky photo - Greg Rakozy  

Book, Thread , and Scissors photo - Eneida Nieves  

Graffiti Bird photo in footer - Hermes Rivera   all photos via StockSnap.io