IMPORTANT INFORMATION AND CLIENT CONSENT FOR PSYCHOTHERAPY

Please review the following information carefully and provide your signature at the end to confirm that you have read and understood it fully.

AVAILABLE SERVICES

Dr. Kacie LaChapelle offers non-emergency Telehealth services for adults including: ongoing individual and group psychotherapy and marriage/relationship counseling.

CREDENTIALS

I am a Licensed Mental Health Counselor (LMHC) in the State of Massachusetts, (License number LMHC3759) and a Licensed Professional Counselor (LPC) in the State of Connecticut (License Number 5694).

GENERAL INFORMATION

Counseling and psychotherapy can be highly beneficial, but like any form of treatment, they come with potential risks:

General risks and benefits:

The therapeutic process often involves discussing personal matters, which may evoke uncomfortable emotions such as anger, guilt, or sadness, distress, intensified emotional triggering, or increased awareness of past trauma. Conversely, potential benefits may include improved personal relationships, reduced emotional distress, and effective problem-solving for specific challenges.

Engaging in the use of distance counseling, technology, and/or social media within the counseling process (i.e. Telehealth):

Telehealth services provide convenience and flexibility, but it’s important to understand some potential risks and limitations. While every effort is made to protect your privacy, electronic communication can be vulnerable to issues such as hacking or unauthorized access.

Additionally, confidentiality laws may vary depending on where you and your therapist are located, which could affect how your information is handled. Technical issues like internet disruptions or software problems could interrupt sessions, and the lack of in-person cues may sometimes lead to misunderstandings or incomplete communication.

Telehealth may not be the best option for everyone, especially in urgent or critical situations where in-person care is necessary. Your therapist will work with you to determine if telehealth meets your needs or if a local referral is more appropriate. It’s also important to verify your identity, and if you’re a minor or a vulnerable individual, your guardian’s consent may be required.

We want you to feel fully informed about the process. You will receive clear information about fees, billing practices, and your therapist’s qualifications upfront. We will also provide guidance on how to contact your therapist if they are offline and discuss the steps in place to address any challenges unique to telehealth services. By understanding these aspects, you can decide whether telehealth is the right choice for you.

PAYMENT AND BILLING

I am committed to transparent, ethical, and lawful billing practices. All fees, including co-pays, are due at the time of service. Services are provided at a rate of $175.00 per 55 minute session, payable prior to each session.

If you are using insurance, I will submit claims on your behalf in accordance with all contractual and legal requirements. As a healthcare provider, I am obligated to bill accurately and truthfully, ensuring that all charges reflect services actually provided. I strictly adhere to relevant laws and will never misrepresent fees or bill for services that did not occur. If you are not using an insurance plan and prefer to file your own claim, full payment is required at the time of service, and I will supply a detailed statement for your records. If you have private insurance with out-of-network benefits, I can provide a superbill (an itemized receipt with required information) upon request, which you may choose to submit to your insurance company. Please note that: (1) I cannot guarantee reimbursement, and (2) You are responsible for understanding your plan’s out-of-network benefits. If your insurance changes or is cancelled, you are responsible for notifying me immediately. You are also responsible for all payments in full for services rendered.

Most insurance plans only cover medically necessary mental health treatment for an identified patient with a diagnosis, and may cover individual or family sessions only when that patient is present and the service meets plan requirements. Couples therapy or relationship-focused sessions not tied to an identified patient’s treatment plan (such as a Therapeutic Disclosure Session) are typically not covered and must be paid out of pocket at our private-pay rate. This also includes fees for reviewing and editing documents, travel time, collateral communication with other providers, or other non-clinical services your plan excludes. I will inform you whenever a service appears non-covered, provide fee information in advance, and offer a Good Faith Estimate upon request (or if you are uninsured/self pay). You are responsible for verifying your benefits, understanding any prior authorization or referral requirements, notifying us of insurance changes, and paying cost-sharing or private-pay fees. If insurance denies or reverses payment, you are responsible for the unpaid amount. We will bill accurately, inform you of coverage issues, and provide itemized receipts or superbills as needed. For questions about coverage, fees, or network status, please contact the practice.

USE OF TESTS AND INVENTORIES

It may be necessary for your Therapist to utilize assessment tools (tests and inventories) during the course of treatment, and for purposes of assessment and diagnosis. These tools will be selected, administered, and interpreted in accordance with applicable Codes of Ethics and standards set forth in both the American Counseling Association and the American Mental Health Counselors Association. Your therapist will provide you with appropriate information regarding the reason for assessment tools and to whom (if anyone) the report will be distributed to. There may be out of pocket costs for the use of certain tools and/or assessments.

CONFIDENTIALITY AND ITS LIMITS

The session content and all relevant materials to your treatment will be held confidential unless you, the client, requests in writing to have all or portions of such content released to a specifically named person/persons. This applies to all information you share and all communications, including electronic communications, shared between you as the client and myself as the therapist. I will never communicate, verbally or in writing, with others about you without your express written consent except in certain situations.

Generally, with your written advance consent, given to me by signing this Notice, I may use and disclose your PHI to the extent necessary for treatment, payment, and health care operations. This includes activities such as filing insurance claims, participating in credentialing reviews, and complying with licensure audits. Additionally, the law may allow for disclosure of your information, without your consent in circumstances including but not limited to:

  • Potential harm to the client or significant or deadly harm to others by the client; 


  • Mandatory reporting of suspected abuse/neglect of children, elders, or persons with disabilities; 


  • Court orders or other legal mandates.

I may also seek consultation from professional colleagues to enhance your care or for my own learning purposes. I will use my best efforts to safeguard your privacy by not disclosing your name or other identifying demographic information, or any other information by which you might be identified by the consultant.

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately and/or legally kept confidential.

Additional Limitations of such client held privilege of confidentiality exist and can be found in detail in the HIPAA Notice of Privacy Practices you received.

CLIENT BILL OF RIGHTS

  1. Informed Consent: By typing/signing my name below, I am signing this Client Informed Consent Form as the Client and I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given an appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive mental health assessment, treatment and services (or for my child if said child is the client) and I understand that I may stop such treatment or services at any time.

  2. Grievance Process: You have a right to file a complaint with the Bureau of Health Professions Licensure if a health care professional or facility violates standards of professional conduct. 


  3. Client Respect: You have the right and ultimate responsibility to determine the best course of treatment for yourself, to disagree with therapist recommendations, and to work in collaboration with your therapist. Despite past actions due to addiction or other reasons, you are entitled to respect and dignity in the therapeutic relationship. 


  4. Right to Terminate: You have the right to stop treatment at any time, for any reason. I may recommend or initiate ending therapy when clinically or ethically appropriate, including when:

  • treatment is no longer necessary, effective, or aligned with your goals,


  • services you need are outside my scope of practice or competence, or a conflict of interest arises, 


  • safety concerns exist, including credible threats or harassment toward me or others in the practice, 


  • there is persistent nonattendance (e.g., repeated late cancellations or no-shows) or loss of contact despite reasonable outreach, 


  • there is persistent nonpayment for services or material changes in coverage/benefits that you elect not to assume, 


  • you decline or are unable to participate in treatment in a way that allows me to provide effective, ethical care.