Contract

Informed Consent for Art Therapy/Psychotherapy

Welcome and thank you for choosing my art therapy practice. The following document serves as a description of treatment and an agreement between you (client) and me (clinician). Our mutual understanding of treatment expectations and goals are essential as we work together. I encourage you to read this document in its entirety and ask any questions that may arise.

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Art therapy, also known as art psychotherapy, is a relatively new modality of mental health treatment that provides clients with a different way of communicating- mainly through visual art. Words may fail us when expressing certain thoughts and feelings, but art gives them a new voice. Art making itself can be relaxing, grounding, and helpful in physical and cognitive development, by strengthening the mind-body connection. It includes, but is not limited to, drawing, painting, photography, textiles, and clay. My responsibility is to provide you with the materials and tools you need to express yourself best- and to provide any art instruction that may aid in you doing so. Art therapy focuses on the process, not the product, meaning that there is no judgment of art ability. It is the experience of art making, the decisions made during, and the discussion around those decisions that are important in art therapy and drive treatment towards growth and healing.

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Reflecting on the art and its creation may be challenging at times, and like in all forms of mental health treatment, may require discussing uncomfortable thoughts, feelings, and events. However, the art provides a safe place to work through these, with the goal of self-reflection, conflict resolution, improving relationships, setting boundaries, and gaining confidence. This happens best within the structure of a strong therapeutic relationship, built on trust and a mutual understanding of expectations, which are described below. If at any time you feel that we are not aligned in your treatment goals, I encourage you to discuss this with me. If you wish to seek another treatment provider, I will make recommendations as needed. Your mental health and wellbeing are the priority.

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CONSENT FOR TREATMENT

I, the client, authorize Erin Viola Jacobsen, MA ATR-BC LCAT to carry out all therapeutic evaluations, treatments, and/or diagnostic procedures that are necessary during the course of my care. I am open to actively partnering in my treatment and understand that my investment is connected to meeting my goals. I understand and agree to the information above for the duration of treatment, unless amended in writing by all interested parties.

Appointment and Professional Fees

APPOINTMENTS

Unless otherwise agreed upon, sessions are 45 minutes long and occur each week at my office at the address above, or through an agreed-upon Telehealth service. For in-person sessions, I will supply the necessary materials and partner with you to determine other resources needed as treatment progresses. Telehealth clients may secure their own supplies or purchase an art kit from me (see Consent for Telehealth Services).

Consistency aids in the success of treatment, and it is important that sessions begin and end on time, even if you arrive late. Any session that begins more than 15 minutes late will be considered a missed appointment and charged at the full rate, as will any appointment canceled within 48 hours of the scheduled session. If the cancellation occurs outside of those 48 hours, no charge will incur and efforts will be made to reschedule.

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If I do not hear from you following a missed session, I will continue to reach out over the course of two weeks following the absence. If I still can not get in contact with you, I will close your case and terminate treatment 30 days from the first missed appointment. I maintain the ability to satisfy any outstanding balances as indicated in the Professional Fees section of this contract.

PROFESSIONAL FEES

I provide complimentary 15-minute introductory phone consultations, after which we will schedule an intake assessment. Intake assessments are 90-120 minutes at a rate of $450-$650. Standard individual art therapy/psychotherapy sessions are $240 for 45 minutes. Art supplies are provided for all in-person sessions, and Telehealth clients have the option to purchase a comprehensive art supply kit for $100, or may purchase their own supplies to use at home.

A prorated session fee may be applicable for additional professional services you may need (reviewing or writing reports, attending meetings as authorized by you, etc.). Such fees will be discussed in advance. Additionally, any phone consultation that exceeds 15 minutes will incur a prorated session fee. 

Session fees may increase at the start of each calendar year, and I will provide notice of any changes at least 30 days in advance.

Payment is due at the time of service, unless arranged otherwise with me. You may enroll in Simple Practice’s credit payment system for automatic withdraws, but please note that all processing fees will be part of your charges (i.e. $8 per session transaction for a 45-minute session). You may also pay via Zelle (TouchstoneArtTherapy@gmail.com). Cash, personal check, Venmo, and Google Pay are also available upon request. I will provide a monthly statement and documentation necessary for out-of-network insurance submissions at the end of each month through Simple Practice. Please notify me if you plan to submit for out-of-network reimbursement. I recommend speaking to your insurance provider in advance regarding reimbursement options for LCATS- Licensed Creative Arts Therapists.

As per the No Surprises Act, you have a right to a Good Faith Estimate (GFE) to provide you with transparency in pricing. This document is included with this contract and a copy should be kept for your records. It highlights the above fee expectations.

For financial security, credit card information is taken at intake, kept on file, and updated as necessary. This information can be used to collect any outstanding balance that remains unpaid for 30 days from date of missed payment. If your account has not been paid for over 60 days and we have not agreed upon a payment arrangement, I have the option of using legal means to secure the balance. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding the client’s treatment is his/her/their name, the nature of the services provided, and the amount of money that is owed.

MINORS

If you are a minor, your legal guardian(s) may be legally entitled to some information about your treatment. I will discuss with you and your guardians what information is appropriate for them to receive and which issues are more appropriately kept private.

TERMINATION

Ending relationships can be difficult, even when due to meeting all therapeutic goals. Regardless of the reason for termination, it is important to have closure and review overall progress and plans for the future. The appropriate length of the termination process depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion about your goals, if I determine that the treatment is not being effectively used, or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason or you request another provider, I will provide you with a list of qualified clinicians to treat you. You may also choose someone on your own or from another referral source. Should you fail to communicate with me for 30 days, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

Contact and Confidentiality

CONTACT OUTSIDE OF SESSION

Maintaining safety is of the utmost importance and the bedrock of a strong therapeutic relationship. This extends to the safety of the information shared with me. Please note that my email and text messages are not encrypted, so I cannot guarantee confidentiality if you choose to share sensitive information electronically. Doing so implies that you acknowledge the risk of possible interception by outside parties when using these forms of communication.

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If you need to reach me outside of your regularly scheduled session, please do so by calling or leaving a voicemail at my work number (914-338-8358) during my business hours: Monday through Friday, Noon-8:00PM. If you need to reach me outside of these hours, please email me at TouchstoneArtTherapy@gmail.com. I will work to respond to you within 24 hours or by the next business day. If a true emergency situation arises, please call 911 or go to any local emergency room. Please be aware that email is never an appropriate vehicle for emergency communication.

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If we see each other outside of session, I will not acknowledge you first in order to maintain your privacy. If you choose to acknowledge me, I will gladly engage in a brief conversation.

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To maintain professional and personal boundaries, I cannot provide therapeutic services for those enrolled in, or working for, the Greenburgh Central School District.

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SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. 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.

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CONFIDENTIALITY

The information you share with me in session is important and private. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule exists to assure your Protected Health Information (PHI) remains safe during treatment so that you may feel confident and secure in the work we do together. Additional information about HIPAA is included in the “Notice of Privacy Practices—HIPAA” document. PHI includes original artwork and photographs of work created in session, as they are extensions of treatment and considered part of the clinical record. I will maintain documentation of the work created, but the physical pieces belong to you, the artist.

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This record of your treatment and artwork are part of the PHI that I maintain. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Written consent will also be needed in instances where more specific information needs to be shared with other providers or parties that we jointly deem beneficial to your treatment. You may also identify professionals with whom I should contact. Consent forms are available digitally or can be download, printed, signed, and either uploaded or returned to me in person.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communications between client and clinician. However, there are some exceptions to HIPAA, most notably where individual safety and the safety of others is concerned. Further description of these instances are available in the Notice of Privacy Practices—HIPAA document.

MINORS & PARENTS/GUARDIANS

As with all forms of treatment, growth and progress do not happen in isolation. This is especially true when clients are under 18 years old (not emancipated) and considered a minor. Parental involvement in, and support of, treatment are essential when working with minors, and there needs to be an agreement between a minor client and clinician that pertinent information can be shared with his/her/their parents or guardians when necessary. This is not to violate privacy or trust, but rather to build on progress between sessions.

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It is important to note that while the law may allow parents and legal guardians to examine their child’s treatment records, I encourage them to respect the need for privacy, especially those of older children (ages 12 and older). For these older clients, I request an agreement allowing me to share general information about the progress of the child’s treatment and attendance at scheduled sessions. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents or guardians of my concern.

Notices of Privacy Practices

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 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:

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• 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.

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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 health care provider 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 health care provider in diagnosis and treatment of your condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because 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.

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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.

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III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Session Notes: I do keep “Session notes”, which includes documentation of your artwork, 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 associates to help them improve their clinical skills.

   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 session 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.

2. Marketing Purposes. As a health care provider, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a health care provider, 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:

1. 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.

2. 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.

3. For health oversight activities, including audits and investigations.

4. 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.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. 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.

10. 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.

1. 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:

1. 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.

2. 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.

3. 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.

4. The Right to See and Get Copies of Your PHI. Other than “session 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.

5. 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.

6. 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.

7. 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.
    

EFFECTIVE DATE OF THIS NOTICE

This notice is in effect on January 1, 2025.

Acknowledgement of Receipt of Privacy Notice

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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.

Consent for Telehealth Services

CONSENT FOR TELEHEALTH SERVICES (Zoom, Simple Practice, etc.)

1. I, the client,

   • Understand that Telehealth sessions are available to me on an ongoing basis, and I may opt to receive treatment in this way.

   • Understand that individual sessions could move to a Telehealth platform, if health and safety are at risk.

   • Understand that a Telehealth session offers the benefit of treatment continuing despite Covid-19 and other disruptions to in-person care.

   • Understand that there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my clinician or I can discontinue the Telehealth session if it is felt that the video conferencing connections are not adequate for the situation.

   • Have had a direct conversation with my clinician, 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.

   • Agree to secure a private place for myself, or my dependent, where I or my dependent can speak freely and confidentially with my clinician through video conferencing.

   • Agree to secure a safe place for the storage of art supplies and art works associated with treatment, as my clinician cannot do so while engaging in Telehealth sessions.

   • Understand that Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

   • Recognize that although my provider and I may be in direct, virtual contact through a Telehealth Service, it does not provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

   • Do not assume that my provider has access to any or all of the technical information in the Telehealth 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 for the Telehealth Service.

   • To maintain confidentiality, I will not share my Telehealth appointment link with anyone unauthorized to attend the appointment.
      

   Additionally,

   • My clinician explained to me how video conferencing technology differs from an in-person experience and the impact it may have on therapeutic dynamics.

   • My clinician provided a list of standard art supplies for purchase, which will allow me to better engage in Telehealth art therapy services. I also have the option purchase a comprehensive kit for $100, which will ensure that I have access to the variety of art mediums similar to those receiving in-person treatment. I understand that the safety of the supplies are my responsibility.