Forever Forward Therapy, Jeanie Winstrom, MA, LCPC
Forever Forward Therapy
Therapist and Consultant
Agreement for Psychotherapy
This document contains important information about professional services and business policies related to the psychotherapy your clinician delivers. Please read it carefully and note any questions you might have. When you sign this document, it will represent an agreement between you and Jeanie Winstrom MA LCPC. This document is important. Please take a moment to read it and note any questions you have before signing it.
Psychotherapy can have benefits and risks. As with most other forms of treatments, results cannot be guaranteed.
Participation in therapy can result in a number of benefits to you, including increased insight into your patterns of feeling, thinking, behaving and relating to others; improvement in your relationships; solutions to specific problems you bring forward in therapy; and improvement in symptoms of distress.
Benefits to therapy require openness on the part of the therapy client. When information about your feelings, thoughts, behaviors, relationships, or other difficulties are withheld, it is not possible for the therapist to help you with them or to help you understand how they may be related (or not) to the issue for which you are seeking treatment. Benefits also require consistent attendance in therapy and work both in and outside of therapy sessions.
Since evaluation and/or therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, helplessness, etc. Some people notice an immediate sense of relief when they share their pain with someone else. Others may notice that their symptoms get worse, before they begin to get better. In either case, it’s important to share your reactions to therapy.
When these feelings come up, it is important to talk to your therapist about them. They may be a natural, tolerable, and expected reactions to your work in psychotherapy. Other times it may be necessary or preferable to change the pace of your therapeutic work if the feelings are too uncomfortable. Or, if the treatment is not helping, it is important to talk about other treatment options.
How therapy with Jeanie Winstrom works
Your first session/s will involve an evaluation of your needs as well as begin the work of identifying what it is you would like to change about yourself. This time will result in a discussion of your therapy goals and recommendations about how you might reach those goals. You and I will work together to reach a shared understanding of where your problems come from and what factors in your life contribute to keeping those problems in place. This information guides how you will move forward in resolving them. Should either of us determine that the type of treatment I can offer, or the mode of treatment (online) is not a good fit for you, or even if we find that I am not a good fit, I will share recommendations for the right type of treatment and provider.
While the specific methods of therapy will come from our assessment, it may be helpful for you to understand the general process. Initially, our work will be about getting to know and understand you, together. I make this as comfortable as possible by listening carefully, reflecting back what I hear so that you can let me know if I’m really “getting” you, and collaborating with you to form connections between your experiences with your feelings with your thoughts and your impulses or behaviors. We’ll look at your current life, your early life, and even your “life” in the therapy room with me to see if we can find themes that exist in all three areas. When we discover those kinds of thematic issues, it helps us to know that we are working on a “core” issue. Core issues can initially feel harder to work on and can bring up more pain, but ultimately can provide longer term relief. We will also do things to bring immediate relief to areas of suffering – for example if you struggle with sleep or anger or anxiety, we’ll assess it deeply and then practice strategies to overcome it.
If you have unanswered questions about any of the procedures used in the course of your therapy, their possible risks, the clinician’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
Therapy may also involve recommendations or referrals to additional services that support your wellness (e.g. psychiatrist, neuro psychologist, physician). In some cases these treatments are so vital and central to your recovery that your clinician is unable to ethically continue providing therapy without your concurrent treatment with these providers. Failing to follow these recommendations may result in impaired treatment progress, suicidal thoughts or actions, deteriorating medical condition, termination of treatment with this clinician or even death. Most often, however, these are recommendations not requirements.
Most often I use Secure Video for video sessions, because it is encrypted and fully HIPAA compliant. I encourage clients to do a test log in prior to our appointment to make sure that everything is working well on their side. You can check that your mic, speakers, and video are working this way. The Secure Video troubleshooting team are fantastic so if you run into any trouble, just give them a call.
It takes a few seconds after you log into the waiting room for us to show up on each other’s screens. That’s normal. If it seems to be taking an inordinate amount of time, feel free to text, email, or call me so that we can troubleshoot together.
Please be sure to EXIT out of any programs that steal bandwidth prior to our sessions. QUIT (don’t just minimize) skype, carbonite, google drive back up, or any other cloud backup service. Please ensure that no one in your home is streaming video or playing graphic heavy online video games as this will decrease our internet connection.
Tech issues are rare and usually very easy to solve. Turning things off and back on again typically fixes most issues.
Additional Pro-Tips for Online Therapy
Inadequate privacy prior to the session. Psychotherapy is serious work. You do not want to be interrupted.
Turn off notifications on your computer and phone once we are connected.
Consider having tissues handy. If you were in my office, I’d provide them for you.
You may be extra cozy because you are somewhere familiar to you and you may feel more casual because the work is online and you are used to socializing that way. Remind yourself prior to the session that you are here to do the meaningful work of positive change.
Research says that the connection between therapist and client is the primary determinant of therapeutic change. I want to make sure that we connect well over video so in our first session, I’ll share some tricks to make sure that we can look at each other, rather than the camera, when we talk. If it looks off to you, please let me know. Eye contact matters.
Emergency and Crisis Support
I do NOT provide 24-hour crisis services. If a life-threatening crisis should occur, contact a crisis hotline, call 911, or go to a hospital emergency room. As an individual provider who is not in a group practice, I am generally in a therapy session during working hours and am unavailable outside of working hours. If it is likely that you may need crisis support, let’s discuss this so that I can be sure you have the level of care you need. You deserve support that matches your needs.
Strengths and Limitations of Online Psychotherapy
Telephone, secure chat, and video sessions have some advantages over in-person psychotherapy. Many of my clients share with me that it is more convenient (no commute) and more comfortable (in their own space). Some clients share that they feel more able to share “deep” things because it is online rather than in person.
Online therapy is not for everyone. If a client has a poor internet connection, a lack of privacy, or otherwise would simply be more comfortable meeting in person, it is better to connect them with a provider who offers that service. It is important to consider if this applies to you and may impact your therapeutic progress and select an in-person provider if so. In some clinical situations, such as crises or suicidal or homicidal thoughts, in-person treatment may be the most appropriate treatment choice.
Location of Services
Online therapy allows me to provide services to a broader geographic range of clients than in person services. I am a licensed clinical professional counselor in Montana, a licensed professional counselor in Alaska, Georgia, Minnesota and Wyoming and a licensed mental health counselor in Washington. In limited cases, I am able to serve clients in other states and countries. In those cases, be aware that I will adhere to the legal regulations of my home state of Montana.
Confidentiality is the cornerstone of psychotherapy and psychological services. Your verbal and written communication with me is held in the strictest confidence and will only be disclosed to other parties with your written authorization. (Please consider the limits of confidentiality in electronic communications, outlined in more detail later.)
Exceptions to this include your presentation of imminent danger to self or others; knowledge of suspected child abuse, neglect, or abandonment; knowledge of suspected elder/vulnerable adult abuse, neglect, or exploitation; naming me in a lawsuit; claiming emotional harm or damages in a lawsuit with another entity; or by a court order signed by a judge (a subpoena alone will not result in disclosure).
Additionally, communication with me via any online or electronic means (e.g. email, text, video chat ) is limited in security and thus your confidentiality may not be guaranteed.
In the event of an injury, illness, or other unexpected emergency situation that results in me becoming unavailable, your basic contact information (name and contact numbers or email) may be provided to a fellow clinician or associated professional. This will allow for your timely notification of appointment cancellations, as well as provide you with an opportunity to obtain further information regarding your continued care.
Considering all of the above exclusions, if it is still appropriate, upon your request, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way. Depending on the nature of the request and the time involved, there may be a fee for this service.
Confidentiality and Social Interactions
Should we run into each other socially in person or online, I will never acknowledge working therapeutically with you. In order to protect our relationship, I cannot accept invitations to social events or social media requests. While you are welcome to visit my professional social media pages or website, I would discourage you from leaving messages there or “following/subscribing” simply to better protect your privacy and anonymity.
Confidentiality Policy in Emergencies
Should you enter a medical or psychological emergency, I need to know your location so that I am able to get help to you. Please share the location from which you will be conducting our sessions in your client portal.
Please note that you will need to share your location with me at the beginning of the session should it be different from the one listed in your client profile.
Should you need physical or emotional assistance (e.g. approaching a psychological emergency but not at the threshold of needing to be hospitalized or feeling dizzy but not in need of an ambulance), I would like to be able to contact someone to assist you. Please provide two emergency contacts, their relationship to you, their phone numbers, and email address within the client portal. You agree that I may, but am not required to, contact either of these people if I am concerned for your safety. In the case that I have dire concerns for your safety, I will do all that I can to protect you, including calling 911 or other emergency responders.
Please ensure that your emergency contacts speak both English and the native language of the country you are living in so that I am able to get help to you.
Confidentiality of Email, Chat, Cell Phone, Video, and Fax Communication
I use secure and encrypted video software for our sessions, and secure email and phone systems for other communications. However, I want you to be aware that if you do not also use secure/encrypted programs on your side of the communication, the communications may not be secure. As a result, I start at a place of sharing as little as possible via these channels and will adapt to your comfort, with documentation, as we proceed. Security laws state that clients have the freedom to request or opt in to less secure means of communication if they are aware of the risks, comfortable with them, and find it clinically helpful to do so.
I also want to acknowledge that while I regularly check in on the security of all of our ways of communicating, swift advances in technology preclude my ability to be certain of our security. Just as I cannot guarantee a physical office space isn’t broken into, I also cannot guarantee the absolute security of our work online.
Please ensure that you too are doing your utmost to protect your privacy by considering who has access to your email, text messages, and so on before choosing online therapy. For example, I would discourage you from using your work email for our communications. Another way to protect your privacy is to be sure to fully exit all online counseling sessions and emails before leaving your computer.
I consult regularly with other professionals regarding my clients to provide the best care possible; however the client’s name or other identifying information is never disclosed. The clients’ identity remains completely anonymous and confidentiality is fully maintained.
Not all dual relationships are unethical or avoidable. However sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair your clinician’s objectivity, clinical judgment or therapeutic effectiveness, nor that could be exploitative in nature.
Rates, Billing, and Payments
We have discussed and agreed upon the following rates:
50 minute Evaluation Initial Session $400
Family or Couples Session $300
50 minute Psychotherapy Sessions $250
Ongoing psychotherapy typically occurs weekly for 50 minutes a session on a time and day agreed upon. Once the appointment is scheduled, you will be expected to pay for it unless you provide at least 48 hours notice.
Self Pay Clients
You will be invoiced the day of our sessions. If the session was missed without 72 hours notice, it will be invoiced at the full fee. The credit card held on file for your account will be charged unless another arrangement has been made ahead of time. If requested, your insurance company can be billed for the sessions held with payment assigned to you. Depending on your coverage, you may be able to obtain partial reimbursement for our session.
If you have provided insurance information for an insurance company that I am in network with, your insurance will be billed the day of our sessions. If the session was missed without 72 hours notice, it will be invoiced to you at the full fee. The credit card held on file for your account will be charged unless another arrangement has been made ahead of time. Once the insurance EOB is issued, the card on file will be charged for any copay or deductible amount due.
If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, it’s costs will be included in the claim. In most collection situations, the only information I release regarding a client’s’ treatment is his/her name, the nature and dates of services provided, and the amount due.
Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 72 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.
No showing for an appointment may be considered a termination of services.
Other professional fees
The base session charge of $250 will be used to calculate other professional services you may need, and will be broken down into 15 minute increments when services are provided for periods of time outside of those detailed above. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and time spent performing any other service you may request.
If you become involved in legal proceedings that require your clinician’s participation, you will be expected to pay for all professional time even if your clinician is to testify for another party. Because of the labor intensity of legal involvement, your clinician charges 500.00 per hour for preparation, driving time, and attendance at any legal proceeding. If out of the area travel is required, additional fees for lodging, meals and lost income will also be imposed at the discretion of the therapist. Please take note of your agreement to avoid involving your clinician in legal proceedings (below).
The fee to complete a work related LOA or other form is $1000 – and is due up front via credit card regardless of the outcome or determination by your human resources department. Please ask your primary medical provider to assist you with any leave of absence requests as they are the most appropriate professional to complete them.
Contacting your clinician
I answer emails as quickly as possible but I am often not immediately available due to many professional responsibilities. Please email during normal business hours. Your email will be returned as soon as possible.
If you are ever experiencing a life-threatening or harm-producing emergency please call “911” or go to your nearest emergency room.
Methods of communication
Some clients appreciate the convenience of having appointment reminders sent to them through email, appreciate being able to receive and pay invoices over email, or to share relevant paperwork in these ways.
Please be aware that basic demographic details like your name, email, and location are considered Protected Health Information (PHI) as is anything clinical in nature like your diagnosis or clinical material.
I consent to allow Jeanie Winstrom LCPC to use unsecured email, cell phone text messaging, calls, or voicemail to transmit to me the following protected health information: Information related to the scheduling of meetings or other appointments
Information related to billing and payment
Information that is clinical in nature (e.g. treatment summaries, diagnosis)
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means.
The delivery of any electronic communication can be intercepted, misdirected, or delayed. Decisions about this should be thoughtful, collaborative, and mutually acceptable.
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 personal 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. You are welcome to follow my professional Facebook page or Instagram account as these contain important information for clients. If you have questions about this, please bring them up when we meet and we can talk more about it.
Discharged from care
Psychotherapy is best ended with a process of termination and a scheduled final appointment. This will allow you to review therapeutic gains achieved during treatment; develop a plan of action to maintain those gains; identify what other services or activities may still be needed; and to process any emotions that may exist regarding the ending of the therapeutic relationship.
If you decide to end therapy without engaging in the process of termination by not scheduling appointments it will be assumed that you are no longer a client of your clinician and you are, therefore, discharged from care. Clients may be discharged after three weeks or twenty one days of no contact.
Both the therapist and the client have the right to end counseling at any time.
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to 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, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested.
If records are requested by the third party, I do not and will not release an entire medical record without a directive from a judge as there is NO reason for this information to be outside of the security of my electronic health record systems. This is for the protection of you, the client. In most cases, entities request the entire record from medical providers and mental health providers without understanding the ramifications. If records are requested, there is a fee related to this that must be paid up front before the records can be released. In some cases this fee is limited by state regulation and this practice complies with all laws and regulations. In addition, sufficient time must be allowed for the records to be gathered, reproduced and securely transferred to the requesting party. In 99 percent of cases, I complete a summary letter that provides the following; date of intake, diagnosis, dates of sessions held and missed and if the client is still active.
Mediation and Arbitration
All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of you (the client) and I. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney’s fees. In the case or arbitration, the arbitrator will determine that sum.
Your electronic signature indicates that you have read this contract in full; that you understand all that it contains; that you agree to abide by its terms; and that you voluntarily consent to treatment. Additionally, your electronic signature indicates that you understand that I, Jeanie Winstrom, am an independent practitioner; therefore, the providers I may contract with (e.g. my video software, my billing software, etc.) are not responsible for or involved in your (the client’s) care or treatment.