Informed Consents
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This document contains important information about the psychotherapy services offered at Soul Tea Therapy. Please review this information carefully.
General Information- Purpose and Nature of Psychotherapy Services
Psychotherapy is a type of treatment in which individuals experiencing mental health conditions, emotional challenges, or life stressors can talk with a mental health professional for the purpose of creating meaningful change. Therapy is intended to help the individual reach a better understanding of specific problems and work toward resolution of those problems. Your therapist may work with you on symptom relief, improvement in day to day functioning, or simply offer support in problem solving. Through therapy, individuals have the opportunity to learn healthier habits and better understand themselves in order to live happier and healthier lives.
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
The Therapeutic Process - Benefits and Risks
Therapy can have both risks and benefits. Since therapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Participating in therapy may also involve remembering and discussing unpleasant events, feelings, and experiences. These feelings or memories may bother you at work, school, home, or in your relationships. Sometimes, too, it is possible for problems to worsen immediately after beginning therapy. Most of these risks are to be expected when people are making important changes in their lives.
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. It is important to note that, even with the best effort on the part of both you and the therapist, it is not a guarantee that your behavior or circumstance will change. However, you will be supported and met with the very best attempts to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
Participating in therapy may have benefits, such as: reduced stress and anxiety, increased ability to relate to others, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased self-confidence, and increased comfort in school, social, work, and family settings. Progress and success may vary depending upon the particular problems or issues being addressed, your motivation, and life and situational circumstances. Benefits require substantial effort on your part, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts, and behaviors. While there are no guarantees of what you will experience, most patients find that therapy is helpful.
Patient Responsibility
Therapy involves a commitment of time and energy. You will have to work on things both during session and outside of session. In order for therapy to be effective, regular and punctual attendance is essential. If you arrive late to your appointment, your appointment will still end at the designated time. If you cannot keep an appointment, it is your responsibility to call and cancel with 24-hour notice. If you do not call to cancel your appointment and fail to show, this will be considered a no show. Please note that if you have three consecutive no shows or cancellations, your therapist may consider terminating services and close your case. Additionally, your therapist will cancel therapy sessions if you are under the influence of any substance.
Confidentiality:
In general, the privacy of all communications between a client and a therapist is protected by law, unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. In accordance with state and federal laws, your therapist may be legally obligated to make a report to the appropriate entities under the following circumstances:
If the therapist determines that a client is a danger to themselves or are unable to care for themselves. This may include serious intent, threats, or attempts to conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm or suicide.
If the therapist determines that a client poses a serious threat to cause grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person (age 60 or over) or a dependent adult who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena in a legal proceeding for information stated on the subpoena. If your therapist is required to respond to court subpoenas and/or court orders to release information, your therapist will first discuss the issue with you before taking action.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Professional consultation is an important component of therapeutic practice. As such, your therapist may participate in clinical, ethical, and legal consultation with colleagues. During such consultations, your therapist will share only what is clinically necessary without using your name or other identifying information to provide you with the best care possible.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office. If you wish to discuss your case, you are encouraged to contact your provider at the office during regular business hours. Discussing confidential matters in public will be avoided.
Records
The laws and standards of the social work profession require that therapists keep treatment records. You are entitled to receive a copy of your records, excluding psychotherapy notes, unless your therapist determines that seeing them would be emotionally damaging. In these cases, your therapist can send them to a mental health professional of your choice or prepare a treatment summary. Since these are professional records that can be misinterpreted and/or upsetting to untrained readers, if you wish to see your records, it is recommended that you review them with your therapist so that they can discuss the contents and answer any questions. Records will be released to you and/or another party after securing all necessary signed authorizations and written record requests. You may need to provide a copy of your ID, and there may be a fee to request such documents. It is necessary to provide your therapist at least a 30-day notice to prepare any documentation. All client documents are kept in a locked file cabinet or by a secured online practice management software system.
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TELEHEALTH SERVICES:
Telehealth refers to the mode of providing therapy services remotely through platforms such as video or telephone. Telehealth can have potential benefits, such as easier access to care, easier continuity of care, and accessing services without the client and therapist being in the same location. Telehealth, however, requires technical competence, carries inherent risks, and has differences from in-person therapy.
Appropriateness of Telehealth
Your therapist will need to assess and determine appropriateness for telehealth services. If your therapist determines that telehealth services are appropriate, they will recommend moving forward in treatment via the use of a HIPAA compliant video platform. Your therapist will continue to assess and determine whether telehealth is or is not appropriate throughout the course of treatment. Should telehealth services no longer be appropriate for treatment, your therapist will provide referrals to professionals who can provide appropriate services.
Limitations and Risks
Since telehealth sessions take place with the client located outside of the therapist’s private office, there is potential for privacy and confidentiality issues. It is important for you to make sure you find a private place for your session where you will not be interrupted and cannot be overheard.
Your therapist will use updated encryption methods and HIPAA-compliant video platforms to help keep your information private, but there is a risk that your electronic communications may be compromised, unsecured, or accessed by others. You should take reasonable steps to ensure the security of your communications (such as only using secure networks and having passwords to protect your devices).
Since telehealth requires the use of technology, you may have sessions interrupted due to technology issues or internet connectivity issues.
Most research shows that telehealth is about as effective as in-person therapy. However, some therapists and clients believe that something is lost by not being in the same room, such as non-verbal information.
Your therapist may recommend in-person services and termination of telehealth therapy should you require higher levels of support, such as when a client is experiencing significant crisis situations (e.g significant risk of danger to self or others, among other circumstances).
Emergencies and Technology
Assessing and evaluating threats and risk can be more difficult when conducting telehealth. To address some of these difficulties, your therapist will create an emergency plan with you before engaging in telehealth services. They may ask you to identify an emergency contact person who is near your location and who they may contact in the event of a crisis or emergency to assist in addressing the situation.
If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call your therapist back; instead, call 911 or go to your nearest emergency room.
If the session is interrupted and you are not having an emergency, disconnect from the session and your therapist will wait two 2 minutes and then attempt to contact you via the telehealth platform on which you were receiving services. Your therapist will attempt to reach you twice. If you do not receive a call back within two minutes, you may call Soul Tea Therapy at 805-500-6576.
If there is a technological failure and you are unable to resume the connection, your therapist will contact you when they are able in order to reschedule or confirm your next appointment.
Patient Rights and Responsibilities
You have the right to withhold or withdraw consent for telehealth services at any time without affecting your right to treatment. The use of telehealth is voluntary, and you can request to continue services in-person at any time. Should in-person services be unavailable, your therapist will provide referrals to professionals who can provide your preferred services.
You have the right to privacy and confidentiality, and the same laws that protect confidentiality of medical information also apply to telehealth. Please refer to the Informed Consent for Psychotherapy form for more information on confidentiality and limits to confidentiality.
You will need certain computer or cell phone systems to participate in telehealth services. You are solely responsible for any cost to obtain any necessary equipment or software to take part in telehealth.
Your therapist will need to know your location during every session in case of an emergency. You will be required to provide the address where you are at the beginning of each session. You must remain at the address given during the entirety of your session.
You will need to inform your therapist if you plan on moving or traveling out of county or state as your therapist will need to determine if telehealth services would be legal and appropriate.
Service Fees
The same fee rates will apply for telehealth as apply for in-person therapy. You will be responsible for paying your session fee after each your session. Additionally, should a session be interrupted due to technology failure, you will be responsible to pay a prorated amount based on how many minutes the session lasted.
Records
Telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. Recording outside of this of any kind, including screenshots, is not permitted. Your therapist will maintain a record of your session in the same way they maintain records of in-person sessions.
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my therapist wishes me to engage in a telehealth psychotherapy session.
My therapist explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct in-person visit due to the fact that I will not be in the same room as my therapist.
I understand that a telehealth session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my therapist or I can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
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Services Rendered
Treatment will be provided by Serena Lee, Licensed Clinical Social Worker (LCSW #121160, licensed in the state of California) at Soul Tea Therapy. All sessions with your therapist will be an average of 50 minutes and will be scheduled on a weekly basis. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance. Any conversation 15 minutes or longer, or a session that is 15 minutes longer than intended, will be considered therapeutic in nature and billed at a prorated cost accordingly.
The therapist will only work within the boundaries of their education, training, and license. Your therapist will continuously assess and evaluate your symptoms throughout the course of therapy. If at any point the therapist determines that your situation requires intervention beyond what they can provide, it is their ethical obligation to refer you out for that service. If this were to occur, your therapist would discuss this process with you.
Structure of Services
The first two to three sessions will involve an evaluation of what brought you to services and will focus on gathering information about your history and current needs. The goal of the evaluation is to determine the best course of treatment for you. It will involve completion of assessment tools and questionnaires. It is important to remember that an extended evaluation is not an agreement for ongoing therapy.
If your therapist determines that services are appropriate, then collaboratively, you and your therapist will work together to establish a treatment plan that will outline your goals for therapy. You and your therapist will agree on specific goals such as symptom reduction, improved communication, establishment of healthy boundaries, processing trauma, or the like. Goals may change as the therapy progresses and should be renegotiated accordingly. Clients can at any time ask questions about their treatment and if you feel your treatment is not helping you, please inform your therapist so that your treatment plan can be revised to most effectively meet your needs.
Appointments and Cancellations
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation or rescheduling of an appointment is less than 24 hours. This is necessary because a time commitment is made to you and is held exclusively for you. The only exceptions that can be made are if you or a family member are experiencing a life-threatening emergency in which cancelling the appointment within 24 hours was impossible under such circumstances.
You will be expected to pay for each session at the time it is held. If you are late for a session, you may lose some of that session time but will still be billed as you would for a full session.
It is your responsibility to be aware of your insurance plan, co-payment coverage, or applicable deductible at the time of service. It is very important that you find out exactly what mental health services your insurance policy covers as you (not your insurance company) are responsible for full payment of fees. It is also important to recognize that if your insurance carrier denies payment for any reason, you are still responsible for paying your bill. If you have any questions about the coverage, please call your plan administrator. It is your responsibility to inform your therapist if your insurance coverage changes. You will be responsible for back payments if there is a gap in communication about new insurance or insurance lapses.
In circumstances of financial hardship, you can speak to your therapist about alternate options. In most cases, if an alternative is offered, you will need to provide income documentation and verification. A $10.00 service charge will be charged for any checks returned for any reason for special handling.
Telephone and Email Accessibility
My office hours are Monday, Tuesday, Friday, and Saturday from 10:00 AM to 8:00 PM. However, you may attempt to contact me outside of office hours if you need to reach me between sessions. I am often not immediately available; however, I will attempt to return your call or email within 24 hours if you leave me a voice message or send an email. The only day I will not be returning calls or emails are Sundays, or if I am sick, on vacation, or on a leave of absence, which you will be informed about.
Please note that face-to-face sessions (in person or video) are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
Electronic Communication
Though the communication platforms that are used to text or email you are HIPAA compliant, I cannot ensure the confidentiality of any form of communication through electronic media. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronics include but are not limited to telephone communication, the Internet, fax machines, email, etc, which are considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
Social Media
Due to the importance of your confidentiality and minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, Instagram, etc). If you have an online presence, there is a possibility that you may encounter your therapist by accident. If that occurs, please do not try to contact your therapist or add your therapist to your contacts through social media.
Adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy, and it is against professional Codes of Ethics to engage in social relationships with current or former clients (for two years after termination of services). It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Termination
All services are voluntary. You have the right to participate in services and may withdraw consent at any time. If you are nearing completion of your treatment, your therapist will discuss your progress and termination of services. Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. You will not be terminated from the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating with your therapist.
Reasons for termination include, but are not limited to:
Successfully meeting treatment goals and readiness from the client to end services
Failure to comply with treatment recommendations
Conflicts of interest
Failure to participate or make progress in therapy
Your needs are outside of the therapist’s scope of competence.
Any verbal, emotional, or physical abusive to the therapist
Failure to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons.
Your therapist may also terminate treatment after appropriate discussion with you if determined that psychotherapy with the therapist has not been effectively used or if you are in default on payment. If therapy is terminated for any reason or you request another therapist, you will be provided with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
You and your therapist have the right to terminate therapy at any time at their discretion. Upon either party’s decision to terminate therapy, your therapist will attempt to ensure a smooth transition by holding a termination session and providing referrals.
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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations:
Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes:
If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
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Under Section 2799B-6 of the Public Health Service Act, mental health care providers are required to provide a “Good Faith Estimate” (GFE) to individuals not enrolled in an insurance plan or who plan to use their out of network benefits. A good faith estimate enumerates the expenses you can reasonably expect to pay for psychotherapy services provided by me.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
A GFE must be furnished within 1 business day of scheduling an appointment. If you schedule an appointment at least 10 business days in advance, you are entitled to receive the GFE within 3 business days after scheduling. A GFE must be provided within 3 business days UPON REQUEST.
A GFE shows the costs of non-emergency psychotherapy services that are reasonably expected for your mental health needs and the estimate is based upon information known at the time the estimate was created.
A GFE does NOT include no-shows, late cancellations, or other services related to crisis care, which by definition are unexpected and cannot be predicted for the purpose of compiling a Good Faith Estimate in advance.
A GFE may also include consultations with client collateral contacts, fees related to paperwork requests, and other legal and administrative fees related to client care, when such items are scheduled in advance.
As the GFE does not include any unknown or unexpected costs that may arise during treatment, you could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more than the GFE, federal law allows you to dispute the bill with the Department of Health and Human Services. You must start the dispute process within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute process. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or contact the No Surprises Help Desk at 1-800-985-3059.
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This Privacy Policy ("Policy") applies to soulteatherapy.com, and Soul Tea Therapy ("Provider") and governs data collection and usage. For the purposes of this Privacy Policy, unless otherwise noted, all references to the Provider include soulteatherapy.com. The Provider’s website is a psychotherapist site. By using the Provider website, you consent to the data practices described in this statement.
Collection of your Personal Information
In order to better provide you with services offered, the Provider may collect personally identifiable information, such as your:
First and last name
Email address
Phone number
If you purchase the Provider’s services, we collect billing and credit card information. This information is used to complete the purchase transaction.
We do not collect any personal information about you unless you voluntarily provide it to us. However, you may be required to provide certain personal information to us when you elect to use certain services. These may include: (a) registering for an account; (b) sending us an email message; (c) submitting your credit card or other payment information when purchasing services. To wit, we will use your information for, but not limited to, communicating with you in relation to services you have requested from us. We also may gather additional personal or non-personal information in the future.
Use of your Personal Information
The Provider collects and uses your personal information in the following ways:
to operate and deliver the services you have requested
to provide you with information, or services that you request from us
to provide you with notices about your account
to carry out the Provider obligations and enforce our rights arising from any contracts entered between you and us, including for billing and collection
to notify you about changes to our soulteatherapy.com or any services we offer or provide through it
in any other way we may describe when you provide the information
for any other purpose with your consent.
The Provider may also use your personally identifiable information to inform you of other services available from the Provider and its affiliates.
Sharing Information with Third Parties
The Provider does not sell, rent, or lease its customer lists to third parties.
The Provider may share data with trusted partners to help perform statistical analysis, send you email or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services to the Provider, and they are required to maintain the confidentiality of your information.
The Provider may disclose your personal information, without notice, if required to do so by law or in the good faith belief that such action is necessary to: (a) conform to the edicts of the law or comply with legal process served on the Provider or the site; (b) protect and defend the rights or property of the Provider; and/or (c) act under exigent circumstances to protect the personal safety of users of the Provider, or the public.
Automatically Collected Information
The Provider may automatically collect information about your computer hardware and software. This information can include your IP address, browser type, domain names, access times, and referring website addresses. This information is used for the operation of the service, to maintain quality of the service, and to provide general statistics regarding the use of the Provider’s website.
Use of Cookies
The Provider’s website may use "cookies" to help you personalize your online experience. A cookie is a text file that is placed on your hard disk by a web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you.
One of the primary purposes of cookies is to provide a convenience feature to save you time. The purpose of a cookie is to tell the web server that you have returned to a specific page. For example, if you personalize the Provider’s pages, or register with Provider’s site or services, a cookie helps the Provider to recall your specific information on subsequent visits. This simplifies the process of recording your personal information, such as billing addresses, shipping addresses, and so on. When you return to the same website, the information you previously provided can be retrieved, so you can easily use the Provider’s features that you customized.
You have the ability to accept or decline cookies. Most web browsers automatically accept cookies, but you can usually modify your browser settings to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the interactive features of the Provider’s services or websites you visit.
Links
This website contains links to other sites. Please be aware that we are not responsible for the content or privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of any other site that collects personally identifiable information.
Security of your Personal Information
The Provider secures your personal information from unauthorized access, use, or disclosure. The Provider uses the following methods for this purpose:
SSL Protocol
Use of Google Form and Google Sheet (HIPAA Compliant under BAA Agreement) for messaging form and data collection of responses
Use of SimplePractice LLC (HIPAA Compliant HITRUST Certified) "Request Appointment" widget if applicable
Use of SimplePractice LLC (HIPAA Compliant HITRUST Certified) Client Portal hyperlink
When personal information (such as a credit card number) is transmitted to other websites, it is protected through the use of encryption, such as the Secure Sockets Layer (SSL) protocol.
We strive to take appropriate security measures to protect against unauthorized access to or alteration of your personal information. Unfortunately, no data transmission over the Internet or any wireless network can be guaranteed to be 100% secure. As a result, while we strive to protect your personal information, you acknowledge that: (a) there are security and privacy limitations inherent to the Internet that are beyond our control; and (b) the security, integrity, and privacy of any and all information and data exchanged between you and us through this site cannot be guaranteed.
Right to Deletion
Subject to certain exceptions set out below, on receipt of a verifiable request from you, we will:
Delete your personal information from our records; and
Direct any service providers to delete your personal information from their records.
Please note that we may not be able to comply with requests to delete your personal information if it is necessary to:
Complete the transaction for which the personal information was collected and provide a good or service requested by you, or reasonably anticipated within the context of our ongoing business relationship with you, or otherwise perform a contract between you and us
Detect security incidents, protect against malicious, deceptive, fraudulent, or illegal activity; or prosecute those responsible for that activity
Debug to identify and repair errors that impair existing intended functionality
Exercise free speech, ensure the right of another consumer to exercise his or her right of free speech, or exercise another right provided for by law
Comply with the California Electronic Communications Privacy Act
Engage in public or peer-reviewed scientific, historical, or statistical research in the public interest that adheres to all other applicable ethics and privacy laws, when our deletion of the information is likely to render impossible or seriously impair the achievement of such research, provided we have obtained your informed consent
Enable solely internal uses that are reasonably aligned with your expectations based on your relationship with us
Comply with an existing legal obligation
Otherwise use your personal information, internally, in a lawful manner that is compatible with the context in which you provided the information.
Disconnecting your Provider’s Account from Third Party Websites
You will be able to connect your Provider’s account to third-party accounts. BY CONNECTING YOUR PROVIDER’S ACCOUNT TO YOUR THIRD-PARTY ACCOUNT, YOU ACKNOWLEDGE AND AGREE THAT YOU ARE CONSENTING TO THE CONTINUOUS RELEASE OF INFORMATION ABOUT YOU TO OTHERS (IN ACCORDANCE WITH YOUR PRIVACY SETTINGS ON THOSE THIRD-PARTY SITES). IF YOU DO NOT WANT INFORMATION ABOUT YOU, INCLUDING PERSONALLY IDENTIFYING INFORMATION, TO BE SHARED IN THIS MANNER, DO NOT USE THIS FEATURE. You may disconnect your account from a third-party account at any time.
Email Communications
From time to time, the Provider may contact you via email for the purpose of providing announcements, promotional offers, alerts, confirmations, surveys, and/or other general communication.
If you would like to stop receiving marketing or promotional communications via email from the Provider, you may opt out of such communications by replying STOP.
Changes to This Statement
The Provider reserves the right to change this Policy from time to time. For example, when there are changes in our services, changes in our data protection practices, or changes in the law. When changes to this Policy are significant, we will inform you. You may receive a notice by sending an email to the primary email address specified in your account, by placing a prominent notice on our Soul Tea Therapy website, and/or by updating any privacy information. Your continued use of the website and/or services available after such modifications will constitute your: (a) acknowledgment of the modified Policy; and (b) agreement to abide and be bound by that Policy.
Contact Information
The Provider welcomes your questions or comments regarding this Policy. If you believe that the Provider has not adhered to this Policy, please contact the Provider at:
Soul Tea Therapy
Serena Lee, LCSW #121160
3345 State St, Unit 3251, Santa Barbara, CA 93130
Email Address: serena@soulteatherapy.com
Phone Number: 805-500-6576
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Agreement between User and soulteatherapy.com:
Welcome to soulteatherapy.com. The soulteatherapy.com website (the "Site") is comprised of various web pages operated by Soul Tea Therapy. soulteatherapy.com is offered to you conditioned on your acceptance without modification of the terms, conditions, and notices contained herein (the "Terms"). Your use of soulteatherapy.com constitutes your agreement to all such Terms. Please read these terms carefully, and keep a copy of them for your reference.
soulteatherapy.com is a psychotherapy Site.
The purpose of this website is to provide information regarding psychotherapy services, provide interested persons access to schedule an appointment with me, submit messages to me, and to provide access for current clients to access their client portal. This website may also include blog publications in relation to my practice.
Privacy
Your use of soulteatherapy.com is subject to Soul Tea Therapy’s Privacy Policy. Please review our Privacy Policy, which also governs the Site and informs users of our data collection practices.
Electronic Communications
Visiting soulteatherapy.com or sending emails to Soul Tea Therapy constitutes electronic communications. You consent to receive electronic communications and you agree that all agreements, notices, disclosures and other communications that we provide to you electronically, via email and on the Site, satisfy any legal requirement that such communications be in writing.
Links to Third Party Sites/Third Party Services
soulteatherapy.com may contain links to other websites ("Linked Sites"). The Linked Sites are not under the control of Soul Tea Therapy and Soul Tea Therapy is not responsible for the contents of any Linked Site, including without limitation any link contained in a Linked Site, or any changes or updates to a Linked Site. Soul Tea Therapy is providing these links to you only as a convenience, and the inclusion of any link does not imply endorsement by Soul Tea Therapy of the site or any association with its operators.
Certain services made available via soulteatherapy.com are delivered by third party sites and organizations. By using any service or functionality originating from the soulteatherapy.com domain, you hereby acknowledge and consent that Soul Tea Therapy may share such information and data with any third party with whom Soul Tea Therapy has a contractual relationship to provide the requested service or functionality on behalf of soulteatherapy.com users and customers.
No Unlawful or Prohibited Use/Intellectual Property
You are granted a non-exclusive, non-transferable, revocable license to access and use soulteatherapy.com strictly in accordance with these terms of use. As a condition of your use of the Site, you warrant to Soul Tea Therapy that you will not use the Site for any purpose that is unlawful or prohibited by these Terms. You may not use the Site in any manner which could damage, disable, overburden, or impair the Site or interfere with any other party's use and enjoyment of the Site. You may not obtain or attempt to obtain any materials or information through any means not intentionally made available or provided for through the Site.
All content included as part of the Service, such as text, graphics, logos, images, as well as the compilation thereof, and any software used on the Site, is the property of Soul Tea Therapy or its suppliers and protected by copyright and other laws that protect intellectual property and proprietary rights. You agree to observe and abide by all copyright and other proprietary notices, legends or other restrictions contained in any such content and will not make any changes thereto.
You will not modify, publish, transmit, reverse engineer, participate in the transfer or sale, create derivative works, or in any way exploit any of the content, in whole or in part, found on the Site. Soul Tea Therapy content is not for resale. Your use of the Site does not entitle you to make any unauthorized use of any protected content, and in particular you will not delete or alter any proprietary rights or attribution notices in any content. You will use protected content solely for your personal use, and will make no other use of the content without the express written permission of Soul Tea Therapy and the copyright owner. You agree that you do not acquire any ownership rights in any protected content. We do not grant you any licenses, express or implied, to the intellectual property of Soul Tea Therapy or our licensors except as expressly authorized by these Terms.
Third Party Accounts
You will be able to connect your Soul Tea Therapy account to third party accounts. By connecting your Soul Tea Therapy account to your third party account, you acknowledge and agree that you are consenting to the continuous release of information about you to others (in accordance with your privacy settings on those third party sites). If you do not want information about you to be shared in this manner, do not use this feature.
International Users
The Service is controlled, operated and administered by Soul Tea Therapy from our offices within the USA. If you access the Service from a location outside the USA, you are responsible for compliance with all local laws. You agree that you will not use the Soul Tea Therapy Content accessed through soulteatherapy.com in any country or in any manner prohibited by any applicable laws, restrictions or regulations.
Indemnification
You agree to indemnify, defend and hold harmless Soul Tea Therapy, its officers, directors, employees, agents and third parties, for any losses, costs, liabilities and expenses (including reasonable attorney's fees) relating to or arising out of your use of or inability to use the Site or services, any user postings made by you, your violation of any terms of this Agreement or your violation of any rights of a third party, or your violation of any applicable laws, rules or regulations. Soul Tea Therapy reserves the right, at its own cost, to assume the exclusive defense and control of any matter otherwise subject to indemnification by you, in which event you will fully cooperate with Soul Tea Therapy in asserting any available defenses.
Arbitration
In the event the parties are not able to resolve any dispute between them arising out of or concerning these Terms and Conditions, or any provisions hereof, whether in contract, tort, or otherwise at law or in equity for damages or any other relief, then such dispute shall be resolved only by final and binding arbitration pursuant to the Federal Arbitration Act, conducted by a single neutral arbitrator and administered by the American Arbitration Association, or a similar arbitration service selected by the parties, in a location mutually agreed upon by the parties. The arbitrator's award shall be final, and judgment may be entered upon it in any court having jurisdiction. In the event that any legal or equitable action, proceeding or arbitration arises out of or concerns these Terms and Conditions, the prevailing party shall be entitled to recover its costs and reasonable attorney's fees. The parties agree to arbitrate all disputes and claims in regards to these Terms and Conditions or any disputes arising as a result of these Terms and Conditions, whether directly or indirectly, including Tort claims that are a result of these Terms and Conditions. The parties agree that the Federal Arbitration Act governs the interpretation and enforcement of this provision. The entire dispute, including the scope and enforceability of this arbitration provision shall be determined by the Arbitrator. This arbitration provision shall survive the termination of these Terms and Conditions.
Class Action Waiver
Any arbitration under these Terms and Conditions will take place on an individual basis; class arbitrations and class/representative/collective actions are not permitted. THE PARTIES AGREE THAT A PARTY MAY BRING CLAIMS AGAINST THE OTHER ONLY IN EACH'S INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PUTATIVE CLASS, COLLECTIVE AND/ OR REPRESENTATIVE PROCEEDING, SUCH AS IN THE FORM OF A PRIVATE ATTORNEY GENERAL ACTION AGAINST THE OTHER. Further, unless both you and Soul Tea Therapy agree otherwise, the arbitrator may not consolidate more than one person's claims, and may not otherwise preside over any form of a representative or class proceeding.
Liability Disclaimer
THE INFORMATION, SOFTWARE, AND SERVICES INCLUDED IN OR AVAILABLE THROUGH THE SITE MAY INCLUDE INACCURACIES OR TYPOGRAPHICAL ERRORS. CHANGES ARE PERIODICALLY ADDED TO THE INFORMATION HEREIN. SOUL TEA THERAPY AND/OR ITS SUPPLIERS MAY MAKE IMPROVEMENTS AND/OR CHANGES IN THE SITE AT ANY TIME.
SOUL TEA THERAPY AND/OR ITS SUPPLIERS MAKE NO REPRESENTATIONS ABOUT THE SUITABILITY, RELIABILITY, AVAILABILITY, TIMELINESS, AND ACCURACY OF THE INFORMATION, SOFTWARE, SERVICES AND RELATED GRAPHICS CONTAINED ON THE SITE FOR ANY PURPOSE. TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, ALL SUCH INFORMATION, SOFTWARE, SERVICES AND RELATED GRAPHICS ARE PROVIDED "AS IS" WITHOUT WARRANTY OR CONDITION OF ANY KIND. SOUL TEA THERAPY AND/OR ITS SUPPLIERS HEREBY DISCLAIM ALL WARRANTIES AND CONDITIONS WITH REGARD TO THIS INFORMATION, SOFTWARE, SERVICES AND RELATED GRAPHICS, INCLUDING ALL IMPLIED WARRANTIES OR CONDITIONS OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE AND NON-INFRINGEMENT.
TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT SHALL SOUL TEA THERAPY AND/OR ITS SUPPLIERS BE LIABLE FOR ANY DIRECT, INDIRECT, PUNITIVE, INCIDENTAL, SPECIAL, CONSEQUENTIAL DAMAGES OR ANY DAMAGES WHATSOEVER INCLUDING, WITHOUT LIMITATION, DAMAGES FOR LOSS OF USE, DATA OR PROFITS, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE USE OR PERFORMANCE OF THE SITE, WITH THE DELAY OR INABILITY TO USE THE SITE OR RELATED SERVICES, THE PROVISION OF OR FAILURE TO PROVIDE SERVICES, OR FOR ANY INFORMATION, SOFTWARE, SERVICES AND RELATED GRAPHICS OBTAINED THROUGH THE SITE, OR OTHERWISE ARISING OUT OF THE USE OF THE SITE, WHETHER BASED ON CONTRACT, TORT, NEGLIGENCE, STRICT LIABILITY OR OTHERWISE, EVEN IF SOUL TEA THERAPY OR ANY OF ITS SUPPLIERS HAS BEEN ADVISED OF THE POSSIBILITY OF DAMAGES. BECAUSE SOME STATES/JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, THE ABOVE LIMITATION MAY NOT APPLY TO YOU. IF YOU ARE DISSATISFIED WITH ANY PORTION OF THE SITE, OR WITH ANY OF THESE TERMS OF USE, YOUR SOLE AND EXCLUSIVE REMEDY IS TO DISCONTINUE USING THE SITE.
Termination/Access Restriction
Soul Tea Therapy reserves the right, in its sole discretion, to terminate your access to the Site and the related services or any portion thereof at any time, without notice. To the maximum extent permitted by law, this agreement is governed by the laws of the State of California and you hereby consent to the exclusive jurisdiction and venue of courts in California in all disputes arising out of or relating to the use of the Site. Use of the Site is unauthorized in any jurisdiction that does not give effect to all provisions of these Terms, including, without limitation, this section.
You agree that no joint venture, partnership, employment, or agency relationship exists between you and Soul Tea Therapy as a result of this agreement or use of the Site. Soul Tea Therapy's performance of this agreement is subject to existing laws and legal process, and nothing contained in this agreement is in derogation of Soul Tea Therapy's right to comply with governmental, court and law enforcement requests or requirements relating to your use of the Site or information provided to or gathered by Soul Tea Therapy with respect to such use. If any part of this agreement is determined to be invalid or unenforceable pursuant to applicable law including, but not limited to, the warranty disclaimers and liability limitations set forth above, then the invalid or unenforceable provision will be deemed superseded by a valid, enforceable provision that most closely matches the intent of the original provision and the remainder of the agreement shall continue in effect.
Unless otherwise specified herein, this agreement constitutes the entire agreement between the user and Soul Tea Therapy with respect to the Site and it supersedes all prior or contemporaneous communications and proposals, whether electronic, oral or written, between the user and Soul Tea Therapy with respect to the Site. A printed version of this agreement and of any notice given in electronic form shall be admissible in judicial or administrative proceedings based upon or relating to this agreement to the same extent and subject to the same conditions as other business documents and records originally generated and maintained in printed form. It is the express wish to the parties that this agreement and all related documents be written in English.
Changes to Terms
Soul Tea Therapy reserves the right, in its sole discretion, to change the Terms under which soulteatherapy.com is offered. The most current version of the Terms will supersede all previous versions. Soul Tea Therapy encourages you to periodically review the Terms to stay informed of our updates.
Contact Us
Soul Tea Therapy welcomes your questions or comments regarding the Terms:
Soul Tea Therapy
Serena Lee, LCSW #121160
3345 State St, Unit 3251, Santa Barbara, CA 93130
Email Address: serena@soulteatherapy.com
Telephone number: 805-500-6576
Effective as of Feb 03, 2025
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Disclaimer for Soul Tea Therapy
If you require any more information or have any questions about our site's disclaimer, please feel free to contact us by email at serena@soulteatherapy.com. Our Disclaimer was generated with the help of the Disclaimer Generator website.
Disclaimers for Soul Tea Therapy
All the information on this website - soulteatherapy.com - is published in good faith and for general information purpose only. Soul Tea Therapy does not make any warranties about the completeness, reliability and accuracy of this information. Any action you take upon the information you find on this website (Soul Tea Therapy), is strictly at your own risk. Soul Tea Therapy will not be liable for any losses and/or damages in connection with the use of our website.
From our website, you can visit other websites by following hyperlinks to such external sites. While we strive to provide only quality links to useful and ethical websites, we have no control over the content and nature of these sites. These links to other websites do not imply a recommendation for all the content found on these sites. Site owners and content may change without notice and may occur before we have the opportunity to remove a link which may have gone 'bad'.
Please be also aware that when you leave our website, other sites may have different privacy policies and terms which are beyond our control. Please be sure to check the Privacy Policies of these sites as well as their "Terms of Service" before engaging in any business or uploading any information.
Consent
By using our website, you hereby consent to our disclaimer and agree to its terms.
Update
Should we update, amend or make any changes to this document, those changes will be prominently posted here.