Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Practitioner

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )







( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Life by Design Informed Consent
Informed Consent

Welcome to Life by Design Wellness! I look forward to coming alongside you to help you with your counseling goals. This document provides information about my office policies as well as other important information for you to understand as part of your informed consent to treatment. This information is in addition to that detailed in the Notice of Privacy Practices. Please read them and if you have any questions, discuss them with me. Your signature at the bottom of this form signifies that you have read, understand and agree to abide by these policies and consent to engage in counseling services.


Professional Disclosure Statement

1.    Life by Design Wellness Mission Statement: Life by Design Wellness seeks to assist people in identifying and achieving healthy solutions for their emotional, behavioral, relational, and spiritual challenges, as well as achieving their personal growth goals.  Counseling services are provided from an integrated theoretical perspective with empirically-based techniques and interventions based on client needs/goals.  For clients who desire, counseling from a biblical perspective that integrates Christian values with empirically-based counseling techniques and interventions is offered.   Life by Design Wellness provides counseling and support without regard to a client's ethnicity, gender, age, marital status, or religious affiliation. 

2.   Therapists:

Randel Duncan, M.A., LPC-S: Randel holds a master's degree in Professional Counseling from Amberton University in Garland, Texas. He is recognized by the Texas State Board of Examiners of Professional Counseling as a Licensed Professional Counselor (License #65076) and also has approved supervisor status. He has met the requirements by the State of Texas under the occupations code, chapter 503 that allows him to provide individual, couples, family and group counseling services. His approach to therapy is integrated. He utilizes interpersonal, affective, cognitive-behavioral, and rational emotive counseling methods and techniques, which focuses on how one's thoughts affect the beliefs and behaviors that follow. He utilizes the Gottman Method in marriage counseling and has completed the Level 1 Training through the Gottman Institute.

Dr. Charity A. Kurz, LPC-Associate: Dr. Kurz holds a Ph.D. in Counselor Education from Pennsylvania State University. She holds a master's degree in School Counseling from Youngstown State University in Youngstown, Ohio. She has met the requirements by the state of Texas under the occupations code, chapter 503 that allows her to provide individual, couples, family, and group counseling services. She is recognized by the Texas State Board of Examiners of Professional Counseling as a Licensed Professional Counselor-Associate (License #​81316​). She is supervised by Randel Duncan, M.A., LPC-S (License #65076). Her approach to therapy is integrated. She uses cognitive-behavioral, affective, interpersonal, reality, and solution-focused techniques. She may also use play techniques and expressive arts, depending on the needs of the client. 

Jennifer Gore, MA, LPC-Associate: Jennifer holds a master's degree in Professional Counseling from Dallas Baptist University.  She has met the requirements by the state of Texas under the occupations code, chapter 503 that allows her to provide individual, couples, family and group counseling services. She is recognized by the Texas State Board of Examiners of Professional Counseling as a Licensed Professional Counselor-Associate (License # 85529​). She is supervised by Randel Duncan, M.A., LPC-S (License #65076). She uses cognitive-behavioral therapy and may also use other evidenced-based techniques depending on the needs of the client.  

Counseling is a collaborative process between you and a therapist to work on areas of dissatisfaction in your life and assist you with life goals. For counseling to be most effective, it is important that you take an active role in the process. The Texas State Board of Examiners governs counseling activities for Professional Counselors for LPC's and Texas State Board of Social Work Examiners for LMSW's. I do not accept clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress. I do not provide custody evaluation recommendations, nor medication or prescription recommendations, nor legal advice, as these activities do not fall within my scope of practice. Benefits and Risks of Therapy: Counseling is both an art and a science. It is also a process in which the client and therapist will discuss a myriad of issues, events, experiences, and memories for the purpose of gaining insight and experiencing positive change in working towards the client's therapeutic goals.   While many individuals show great benefit from counseling, a client's experience, reactions, and results to the counseling process cannot be predicted or guaranteed. The counseling process is intentional in addressing problems that cause internal distress and relational issues. This often results in the client experiencing and confronting uncomfortable issues that may lead you to feel sadness, sorrow, anxiety, or pain. In addition, the counseling process sometimes leads to clients making changes and major decisions that do impact other relationships and circumstances involving family, friends or the workplace. These decisions are a legitimate outcome of the counseling experience as a result of an individual or couple evaluating many of their beliefs and values. Furthermore, symptoms may be intensified and the emotional experience may be too intense to deal with at this time, depending on a client's situation. I will be available to discuss any of your assumptions or possible negative side effects in our work together. It is important to be aware that the success of the therapeutic relationship between you and your therapist depends on quality, collaborative effort.   

5.    Consumer Information/Complaints- An individual who wishes to file a complaint against a Licensed Professional Counselor may write to: Complaints Management and Investigative Section; P.O. Box 141369; Austin, Texas 78714-1369; or call 1-800- 942-5540 to request the appropriate form or obtain more information. File Retention- In the event this counseling practice terminates, your records will be retained in conjunction with professional and ethical standards. 

                                                                                                   Office Policies

6.     Counseling Setting: Counseling is conducted at the Life by Design Wellness offices located at: 133 Chieftain Dr, Suite 105, Waxahachie, TX 75165; or, services can be provided at an agreed-upon location that affords privacy/confidentiality for the client (i.e. church, home).  

7.     Appointments: Individual appointments are scheduled for 50-minute segments. Your appointment time is held exclusively for you. Please arrive on time as you use your own time when you are late.  Length of Therapy- The number of sessions depends on many factors and will be assessed and discussed with you. Therapy will be terminated when goals have been achieved and by mutual consent. An exit session or termination interview will be conducted at the end of therapy. You have the right to terminate therapy at any time

Cancellations: If you find it necessary to cancel an appointment, please contact the office at 469.629.8213 at least 24 business hours in advance (i.e., if your appointment is on a Monday, notify us by Friday at noon, if your appointment is the day after a holiday, notify us the first business day prior to the holiday by noon) or you may be charged the normal fee as if you had attended. Cancellations with less than 24 hours advance notice will be charged the regular session fee as a no-show/late cancellation fee. The provider may also discontinue counseling in the event the client has missed 3 appointments without calling to cancel 24 hours prior to the scheduled appointment. 

Confidentiality: The information you share will be held confidential. I will ask you to sign a release of information form before disclosing any information obtained from your sessions or in writing to any other person or agency, including family members. State law and the ethics of our profession protect your confidentiality, except in the following cases.

The legal exceptions to confidentiality include, but are not limited to, the following:

-        If you make a serious threat to harm yourself or another person, the law requires your counselor to try and protect you or that other person. This notification may include notifying the victim, notifying the police, or seeking appropriate hospitalization.

-        If I believe a child, elder, disabled person, or dependent adult has been or will be abused or neglected, I am legally required to report this to the authorities.

-        If you send a health insurance claim form to your insurance for reimbursement, it will have a mental health diagnosis label and will become part of your permanent medical record. This may be relevant in situations where your medical record is necessary such as, but not limited to, qualifying for insurance, such as life, health, or disability insurance. I may also be required to provide additional details about the nature of your sessions to support medical necessity.

-        In order to provide you with the best service, I may consult with other mental health professionals about your case without revealing your identity.

-        If you are working with a Licensed Professional Counselor Intern or Licensed Clinical Social Worker Intern, your therapist is required to discuss your case on a regularly scheduled basis with his/her Supervisor. The Supervisor is also required to maintain confidentiality.

(If applicable, please complete): I am being supervised by: __________________________________________

If any situation arises that necessitates disclosure of confidential information, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. If you are under 18, a parent or legal guardian(s) may have access to your records and may authorize release to other parties. If I run into you outside of the counseling office, I will protect your confidentiality and wait for you to acknowledge me should you choose to do so.

10.  Electronic Transmission: I cannot ensure the confidentiality of any form of communication through electronic media. Personal content sent via email is not secure and can be potentially compromised.  Therefore, by signing this consent form, you are acknowledging that Life by Design Wellness will not be held liable for personal information that you as the client choose to send via email or text should your confidentiality be compromised.  You also understand that emails should only be used for scheduling or exchanging information pertaining to appointments. Life by Design Wellness (Randel Duncan, MA, LPC-S) will not respond to personal content sent via email unless it is requested. Should you need to speak with your counselor in between sessions regarding topics other than scheduling, you agree to do so by phone.

Records: Client records are held according to Texas State Board of Examiners Professional Counselors - code of Ethics Subchapter C. (681.41).  I am required by law to maintain records of each time we meet or talk on the phone. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. If records are requested for any purpose, my policy is to provide an appropriate summary, as records can be misinterpreted.

12.  Release of Information:  If information needs to be released it will only be done according to state law and with written consent from the client indicating an informed consent of such release. In the case of marital therapy, the client is the couple, not individuals; therefore, all records can only be released when both parties consent in writing or if mandated by the court.   Additional information is provided in our Privacy Policies document.

13.  Incapacitation/Death: I acknowledge that, in the event the undersigned therapist become incapacitated or dies, it will become necessary for another therapist to take possession of my file and records. By signing this information and consent form, I give my consent to allowing a licensed mental health professional selected by the undersigned therapist to take possession of my file and records and provide me with copies upon request or to deliver them to a therapist of my choice.

Fees and Payment: Fees payment will be collected at the time of service; cash, check, Visa, MC, or Discover are acceptable forms of payment. Current rates are posted in the patient portal. A $25 fee will be assessed for all returned checks. The adult accompanying a minor (or guardian of the minor) is responsible for payments for the child at the time of service. Any and all fees related to the collection of delinquent accounts will be the sole responsibility of the client or responsible parties.

Telephone conversations, site visits, report writing and reading, consultation with other professionals, the release of information, reading records, longer sessions, travel time, etc.... will be charged at the standard rate in the fee schedule, unless indicated and agreed upon otherwise. Cost of business increases may occur periodically. You will be notified well in advance of any increase.

Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. If requested, I will provide you with a copy of your statement on a monthly basis or for any individual session for which you request one, which you can then submit to your insurance company for reimbursement if you so choose. You must be aware that not all issues/problems dealt within counseling are reimbursed by insurance companies and filing may require the release of confidential information such as mental health diagnosis, which could be utilized in future insurance decisions. It is your responsibility to verify the specifics of your coverage and determine if pre-authorization is required.

Fees for sessions with Randel are as follows:

            Initial Assessment Session:        $125 (60-75 minutes)

            Individual Session:                    $90.00 (50 minutes)

            Premarital/Marriage Sessions:   $100.00 (60 minutes)  $150.00 (75 minutes-90 minutes)

            Group Sessions:                        $40.00 (per group session)

            Testing:                                    Based on the assessment and will be discussed with the client

            Utilizing Insurance:                   Copay is due at time of appointment


Fees for sessions with Dr. Kurz are as follows:

            Individual Sessions: $70.00     

            Group Sessions: $40.00 (per group session) unless otherwise advertised


Fees for sessions with Jennifer Gore are as follows:


           Initial Assessment Session: $90 (60-75 minutes if needed for full assessment)
           Individual Session: $65.00 (50 minutes)
           Premarital/Marriage Sessions: $70.00 (60 minutes) $90 (75 minutes-90 minutes)
           Group Sessions: $30.00 (per group session) unless otherwise advertised


15.  Video Taping of Sessions:  In order to provide the highest level of care to clients, your counselor may video/audiotape your sessions for review and consultation, or when sessions occur with no other staff present at the counseling center. This information will be kept confidential and you will be informed if this should take place.  

16.  Therapist Availability/Emergencies: It is our desire to serve you in the best possible manner.  For needs outside of sessions, such as scheduling or other concerns, please contact the office at 469.629.8213.  Please keep in mind that I do not answer calls during sessions with clients.  I will attempt to return non-emergency calls within 24 hours.   If you experience an emergency situation for which you feel immediate attention is necessary, I will attempt to accommodate a short notice appointment.  However, if that is not possible or the circumstances require immediate intervention, please contact emergency services (911) immediately, the NTBHA 24-hour Helpline, 866-260-8000 (Ellis, Kaufman, Navarro Counties) or go to your nearest hospital emergency room. I will follow those emergency services with standard counseling during regular business hours. Keep in mind that while I may be in

the office I do not answer the phone while in session with a client. Please do not use e-mail, text, and faxes for emergencies.

17. Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to the many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc....), neither you (client) nor your attorney's, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will disclosure of the psychotherapy records be requested unless otherwise agreed upon. If you do become involved in litigation requiring your therapist's participation, you will be expected to pay for the professional time even if your therapist is compelled to testify by another party. 
18. Social Media Policy: To protect the boundaries of our relationship no connection will be created to any counselor's personal social media account such as Facebook, Twitter, Linked In, etc. However, we do have professional business pages available to remain connected with our practice.

19.  Minors:  Minors must have parental consent for counseling with the exception that the client: is 16 years of age or older and resides apart from the parents/guardians and manages his/her own financial affairs; is thinking about suicide; has concerns about alcohol or drug addiction/dependency; or is being sexually, physically, or emotionally abused. Consenting parents have the right to examine the treatment records of children under the age of 18; however, in order that minors may have the trust of a protected environment, it is your counselor's practice to ask parents to forego that right (they are willing to discuss progress with the parent/guardian) with the exception of extreme circumstances (see confidentiality above).    At the termination of treatment and upon request, your Counselor will provide the parent(s)/guardian(s) with a summary of treatment. It is important to note that in the state of Texas children under 17 may not have consensual sex (by law it is considered indecency with a child and therefore "child abuse'') and the state requires a therapist to breach confidentiality and report such activity to Child Protective Services. If your counselor is required to make such a report to CPS about your child, you will be informed as well.  

20.  Professional Consultation.  Professional consultation is an important component of a healthy psychotherapy practice.  As such, I regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, I will not reveal any personally identifying information regarding you or your situation.   

21.  Termination/Referrals: The length of your treatment and the timing of the eventual termination of your treatment depends on the specifics of your treatment plan and the progress you achieve. If at any time you determine you want another professional's opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, will provide him or her with the essential information needed. You have the right to terminate therapy at any time.

22.  HIPAA/HITECH:  Life by Design Wellness is required by law to maintain the privacy of and provide individuals with a copy of our "Notice to Privacy Practices" of our ethical and legal duties in regard to your protected health information in all forms (i.e. all paper and/or electronic data). A copy of this notice is on our website, attached with this informed consent and available in paper form. A copy will be provided to you at no cost upon your request.  . If you have any objections to the Notice, please ask to speak with our HIPAA/HITECH Certified Office Administrator in person or by phone at our main phone number. 


I have read, understood, agree, and consent to the above conditions of service stated. I have also received the notice of privacy practices on this date and have had the opportunity to ask questions about and understand these policies.


Client Signature                                                                                                            Date

Client Signature                                                                                                            Date


(**For Minors Only) I give permission for this minor child(ren) to receive counseling without a parent or guardian present. I have the legal authority to seek and grant permission for professional services for a minor child, there being no legal decree disallowing my authority to assume such responsibility.

Parent Signature                                              Parent Printed Name                            Date


Release of Information Authorization to Third Party

I authorize Randel Duncan, MA, LPC-S to disclose case records, such as diagnosis, summaries, and other requested information, to the insurance company for the purpose of receiving payment directly to our office. I understand that access to this information will be limited to determining insurance benefits, and will be accessible only to persons whose employment is to determine payments and/or insurance benefits. (_______) initial


Payment Contract for Services (these are for Randel Duncan; session fees vary for other therapists)

Full payment is due at the time of service. Payment methods include: Check, Cash, Visa/MC/Discover/Amex. A $25 fee will be assessed for all returned checks. Clients using charge cards may sign below allowing the provider to automatically submit charges to the charge card after each session and can change payment method or charge cards at any time.

Federal Truth in Lending Disclosure Statement for Professional Services

Part One          Fees for Professional Services

$    125          Initial Intake Session 

$      90         per visit (defined as 50 minutes)   $ __35-50_______for testing (as needed/requesed)

$  100/150    per marriage session, depending on length (60 min or 90 minutes)

$___50 ____ is charged for missed appointments or cancellations with less than 24 hour notice.

$___25_____is charged in 15 min increments for any phone/email communication greater than 5 minutes.

$___100____per hour is charged for report writing and preparation.

$___250____per hour is charged for court/attorney consultation and/or time spent in litigation.


Part Two          Charges:

Clients are responsible for full payment at the time of services, including testing fees. Services will be terminated if timely payment is not made as agreed to by this consent.


Part Three       Minors:

The adult accompanying a minor (or guardian of the minor) is responsible for payments for the child at the time of service. Unaccompanied minors will be denied non-emergency service unless charges have been preauthorized to an approved credit plan, charge card, or payment at the time of service.

Thank you for understanding the financial policy and payment contract. Please let us know if you have any questions or concerns.

I (we) have read, understand, and agree with the provisions of the Financial Policy and Payment Contract for Services.


Person responsible for account: __________________________________                                  Date: ___/___/___


( Type Full Name )
( Full Name )
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND KEEP A COPY FOR YOUR RECORDS.
I. OUR RESPONSIBILITIES: We are required by applicable federal and state law to maintain the privacy of your health information and inform you of our privacy practices, legal obligations, and your rights concerning your health information. We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted will be posted on our website and can be made available at your next appointment.

II. WHAT IS “PROTECTED HEALTH INFORMATION” (PHI)? Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the client and relates to the client's past, present or future physical or mental health or condition and related health care services.

USES AND DISCLOSURES OF INFORMATION: Under federal law, we are permitted to use and disclose protected health information, excluding psychotherapy notes, without authorization for treatment, payment and health care operations.

III. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE? Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.

IV. HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
- Medical information may be used to justify needed patient care services, (i.e., treatment protocols).
- We will use medical information to establish a treatment plan.
- We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and providers, therapists, etc.)
- We may use medical information for the supervision of LPC and LMSW Interns or in consultation with other professionals.
- We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment). We will submit only the minimum amount of information necessary for this purpose.
- We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.
- We may contact you to remind you of your appointment by calling, emailing, or texting you.
- We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.

V. WHAT ARE PSYCHOTHERAPY NOTES? Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.

VI. WHAT IS PSYCHOSOCIAL INFORMATION? Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.

VII. SHARING INFORMATION WITH BUSINESS ASSOCIATES
There are some services provided through contracts with business associates. Examples include billing services and receptionist services. When these services are contracted, we may disclose information as relevant to the business associate so that they can perform the job we have contracted them to do.

VIII. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?
The law requires that some information may be disclosed without your authorization in the following circumstances:
- In case of an emergency
- If you appear to pose an imminent threat to yourself or others, in order to reduce the likelihood of harm
- When there are communication or language barriers
- When ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even without a court order
- When required by law
- When there are risks to public health
- To conduct health oversight activities
- To report suspected child abuse or neglect or abuse/neglect to other disabled persons
- To specified government regulatory agencies including proof of compliance with regulations that safeguard your information
- To coroners, funeral directors, and for organ donation

IX. YOUR PRIVACY RIGHTS
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

1. You have the right to inspect and copy your health information.
This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. All requests must be in writing. We reserve the right to deny access to your records. We will charge a fee for the costs of copying and sending you any records requested. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

2. You have the right to request a restriction of your health information.
This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction (such as non-disclosure to health insurance) by contacting your counselor.

3. You have the right to request to receive confidential communications by alternative means or at alternative locations.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.

4. You have the right to request amendments to your health information.
This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing and explain why the information should be amended.

5. You have the right to receive an accounting of disclosures of your health information.
You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.

6. You have the right to receive a paper copy of this Notice of Privacy Practices.

X. WHAT IF I HAVE A QUESTION / COMPLAINT?
If you have questions regarding your privacy rights, please speak to your counselor directly. If you believe your privacy rights have been violated, you may file a complaint by contacting your counselor, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:

Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth St., S.W., Atlanta, GA 30303-8909, (404) 562-7886 (phone), (404) 562-7881 (fax), (404) 331-2867 (TDD), www.hhs.gov/ocr/hipaa

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

In our Notice of Privacy Practices, we provide you information about how Duncan Counseling can use or disclose your mental health and medical information. As described in our Notice of Privacy Practices, we request your consent for any use or disclosure of mental health and medical information necessary to carry out treatment, payment or health care operations. Be advised that my Notice of Privacy Practices is subject to change. The most recent version will always be at my website at www.randelduncanlpc.org. If you have any questions about my Notice of Privacy Practices or if you need to request a copy, please contact me at the address and /or phone number below.

You have the right to revoke this Consent in writing at any time, except where we have already used or disclosed your health information in reliance upon this Consent.

I acknowledge receipt of the Notice of Privacy Practices of Duncan Counseling and consent to the use and disclosure of my personal health information for treatment, payment or health care operations, as described in the Notice of Privacy Practices.
( Type Full Name )
( Full Name )
Client Rights in Counseling
Client Rights in Counseling
Your Rights As A Client.
- Communication. Right to request how I contact you to maintain your confidentiality.
- Suggestions. You are invited to suggest changes in any aspect of the services provided.
- Civil Rights. Your civil rights are protected by federal and state laws.
- Cultural/Spiritual/Gender Issues. You may request services from someone with training or experiences from a specific cultural, spiritual, or gender orientation. If these services are not available, I will help you in the referral process.
- Treatment. You have the right to take part in formulating your treatment plan.
- Denial of services. You may refuse services offered to you and be informed of any potential consequences.
- Medical/Legal Advice. You may discuss your counseling with your doctor or attorney.

Your Rights To Receive Information.
- Risks and benefits. You have the right to be informed of the risks and benefits associated with counseling.
- Costs of services. I will inform you of how much you will pay before your first visit.
- Termination of services. You will be informed as to what behaviors or violations could lead to termination of services.
- Confidentiality. You will be informed of the limits of confidentiality and how your protected health information will be used.
- Policy changes.

My Ethical Obligations.
- I dedicate myself to serving the best interest of each client.
- I will not discriminate between clients or professionals based on age, race, creed, disabilities, handicaps, preferences, or other personal concerns.
- I maintain an objective and professional relationship with each client.
- I respect the rights and views of other mental health professionals.
- I will appropriately end services or refer clients to other programs when appropriate.
- I will evaluate my personal limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self-improvement. I will continually attain further education and training.
- I hold respect for various institutional and managerial policies, but will help improve such policies if the best interest of the client is served.

Client's Responsibilities.
- You are responsible for taking an active role in the counseling process.
- You are responsible for your financial obligations as outlined in the Payment Contract for Services.
- You are responsible for following the policies of this office.
- You are responsible to treat staff and fellow clients in a respectful, cordial manner in which their rights are not violated.
- You are responsible to provide accurate information about yourself.
( Type Full Name )
( Full Name )
Informed Consent for Telehealth Services

Important note: Clients utilizing telehealth services will need to agree the following steps as part of provided telehealth sessions:

1. A fully completed/signed Emergency Contact Release of Information with accurate information.

2. The client will provide their counselor with the physical address of their location during session.

3. Clients will provide counselors with the local contact information of emergency services.  

4. Clients will need to have a stable internet connection that can fully support video streaming while providing them a confidential environment.     

Definition of Telehealth: Telehealth involves the use of electronic communications to enable Life by Design Wellness counselors to connect with individuals using live interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have the rights with respect to telehealth:

1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth services. A copy of our Office Policies and Informed Consent can be provided and is also available in the client's Counsol.com portal account.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that:

the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons,

and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.

Life by Design Wellness utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via Counsol.com, our online Electronic Health Records provider.

4. Life by Design Wellness counselors follow their respective board regulations and ethics as set forth by the State of Texas licensing boards.

5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

Patient Consent to the Use of Telehealth:

I have read and understand the information provided above regarding telehealth, will discuss any questions or concerns I may have until all questions or concerns have been answered to my satisfaction prior to engaging in telehealth sessions.  I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained.

I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

( Type Full Name )
( Full Name )